IC13 Bipolar Disorder Flashcards
describe bipolar disorder
Lifelong, cyclical mood disorder
Illness duration dominated by
depressive episodes (depressive state in bipolar is more depressive than in MDD)
pt with bipolar are more likely to…
commit suicide (15x more likely)
1st episode presentation
mania in males, depression in females
Type of delusions with bipolar mania
grandiose
primary cause of bipolar mania
drug induced - antidepressants (typically in the initial few days-2 weeks)
Medical conditions causing mania
- CNS disorders (brain tumor, stroke, head injuries, multiple sclerosis)
- Endocrine or hormonal dysregulation: Cushing’s disease (increase cortisone), hyperthyroidism (increase TH → mania), hypothyroidism (decrease TH → depression)
Medications causing mania
- Alcohol intoxication
- Drug withdrawal states (alcohol, antidepressants, barbiturates, benzodiazepines, opioid)
- Antidepressants
- DA-augmenting agents (CNS stimulants : amphetamines)
- NE-augmenting agents (beta-agonist, NE reuptake inhibitors)
- Steroids
- Thyroid preparations
- Pseudoephedrine
Key feature of bipolar disorder is…
hx of mania/hypomania not caused by any other conditions
Sx of mania
abnormal and persistently elevated/ irritable mood: D.I.G.F.A.S.T
- Distractibility
- Irresponsible (overindulgence)
- Grandiose
- Flight of ideas
- Agitation
- Sleep reduced
- Talkativeness
Manic episode is defined as
at least 3 sx + elevated/expansive mood (or 4 sx if mood is only irritable)
mania vs hypomania
- Manic: sx ≥1 week (functional impairment)
- Hypomanic: sx ≥4 days (no functional impairment, no psychosis)
Important assessment before starting pt on meds
- Mental State Exam (MSE) to assess suicidal/homicidal ideations and risks
- Labs and other investigations (FBC, U/E/Cr, LFTs, TFTs, pregnancy): to exclude other medical conditions
- PGx: HLA-B1502 genotype test mandatory before starting carbamazepine
Goals of tx
reduce frequency, severity & duration of mood episode, prevent suicide
Non-pharm
- Education: recognise early S/S of mania and depression
- Psychotherapy/CBT — only when pt is in listening mood
- Stress reduction techniques
- Sleep hygiene
Adjunct tx for mania
Short course (~3-5 days) PRN benzodiazepine
- to help pt relax and sleep, taper off when condition improved and mood stabiliser optimised
when to start mood stabilisers
start ASAP dont wait (can take tgt with BZD)
for bipolar mania, what mood stabilisers are used?
Lithium, valproate, FGA/SGA (Olanzapine, Quetiapine, Risperidone, Aripiprazole, Haloperidol)
for bipolar depression, what mood stabilisers are used?
Lithium, SGA (quetiapine, olanzapine + fluoxetine), lamotrigine
CI of valproate
pregnancy
does lamotrigine treat mania?
no
can antidepressant be used for bipolar depression? what combination?
yes only as combination: olanzapine + fluoxetine
SE of lithium
(HPENT)
1. fine to coarse tremors
2. polyuria
3. HYPOTHYROIDISM
4. cardiac effects (ECG changes)
5. nausea
- weight gain, fatigue, cognitive impairment, diabetes insipidus (make too much urine)
CL of lithium
not affected by liver, 100% cleared in the kidneys
Sx of lithium toxicity (>1.5mEq/L)
GI SE: nausea, vomiting
CNS SE: lethargy, confusion, coarse hand tremors, slurred speech, coma
Lithium DDI
STAND up
- Sodium depletion
- Thiazides
- ACEi/ARBs — severe increase in Li levels
- NSAIDs
- Dehydration
SE of valproate
SJS/TEN, thrombocytopenia, pancreatitis, increase weight
valproate and lamotrigine DDI
Risk of SJS with lamotrigine (valproate decrease CL of lamotrigine)
SE of carbamazepine
- SJS/TEN
- Agranulocytosis with clozapine
PK of carbamazepine
induces own metabolism and that of other drugs
Lamotrigine SE
- Less sedation and less weight gain than other drugs listed
- Risk of SJS with valproate (lamotrigine half life increased in hepatic impairment and DDI with valproate)
Lithium TDM
take samples 12hrs after previous dose. 5-7 days after initiation or change dose.
valproate TDM
trough sample needed (sample drawn morning before 1st dose of the day). At least 2-3 days after initiation or change dose.
carbamazepine TDM
trough sample needed (sample drawn morning before 1st dose of the day). At least 2-4 weeks to reach steady state (autoinduction effect)
tests before starting mood stabilisers
- pregnancy test (VPA)
- SJS/TEN (lamotrigine, VPA, carbamazepine)
- HLAB1502 (carbamazepine)
- low Na/ renal panel (Li toxicity)
Mx of recurrent depressive episides
long term Li+, quetiapine, olanzapine + fluxoetine
Mx of disorder with rapid cycling (≥4 mood ep per year)
avoid antidepressants/ stimulants (worsen mania)
- optimise valproate, lithium
choice of drug for pregnancy
- avoid VPA
- safe choice: quetiapine, olanzapine, risperidone
choice of drug for liver impairment
Li+
choice of drug for renal impairment
valproate
choice of drug for suicidal behaviour
Li
choice of drug for aggression/ violence
optimise dose of lithium or valproate, consider adding antipsychotics (IM antipsychotics first then switch to PO)
evaluation of tx response
Monitor target sx (mood sx), compliance
