IC13 Mood disorder II - Bipolar disorder Flashcards
What is the main difference between the medication treatment for MDD and bipolar disorder?
Monotherapy is preferred in MDD.
Combination therapy is preferred in Bipolar Disorder
In treating MDD, we aim to limit treatment to monotherapy. However, if patient fails to respond to ≥2 types of antidepressants, we will then use a combination therapy.
For the treatment of bipolar disorder, we often use combination therapy. The management of bipolar disorder often involve the use of:
2nd gen antipsychotics + mood stabiliser.
What is bipolar disorder?
It is a lifelong, cyclical mood disorder with unusual shifts in mood, ranging from extreme highs (mania) to lows (depression).
What is more common among males and females when they have bipolar disorder?
Males are more likely to present w mania.
Females are more likely to present w depression.
Which classes of drug have risks of causing mania in patients?
Classes of drugs that have risk of causing mania:
- Antidepressants
- Dopamine-augmenting agents
- Steroid
- Thyroid preparations.
Antidepressants take time to exert their effects.
If a patient claims to feel better after initiation, it is a sign of mania.
Recall the acronym used to rmb the sx for depression: In.SAD.CAGES
For mania, the acronym used is D.I.G.F.A.S.T.
Can you list out what D.I.G.F.A.S.T. means?
D - distractibility
I - irresponsibility
G - grandiosity
F - Flight of ideas
A - Activity increased
S - Sleep becomes less of a need
T - Talkativeness
What is the duration of elevated mood that is considered hypomania and mania?
Hypomania - elevated mood for at least 4 days, but less than 7 days. (4 ≤ n ≤6 days)
Mania - elevated mood for more than or equals to 7 days (≥ 7 days)
Depression - depressed mood for >2weeks
There are 2 types of bipolar disorder:
1) Bipolar disorder I
2) Bipolar disorder II
What does each type of bipolar disorder represent?
Bipolar I = mania + depressive episodes
Bipolar II = hypomania + depressive episodes
Bipolar II is less severe than Bipolar I.
Bipolar I is a greater cause for concern as pt are more likely to do actions that can cost their life.
If a family member of a patient has a similiar condition and they are taking a medication that works for them, what should you do for the patient?
Start the patient on the same medication as their family member and see if it works.
What are the goals of therapy for bipolar disorder?
- ↓ frequency, severity & duration of mood episodes
- Prevent suicide
What are some non-pharmacological therapy that we can use for patient with bipolar disorder?
- Recognise early S&S of mania and depression
- Undergo psychotherapy
- Stress reduction techniques
- Sleep hygiene
Psychotherapy is usually only effective if pt is in a listening mood.
Bipolar disorder is much easier to treat when the disorder is still in its early stages. In later stages, it can become severe and go out of control.
What is the pharmacotherapy for bipolar disorder?
Recall that bipolar disorder often use combination therapy unlike depression.
- Antipsychotics
- Mood stabilisers - e.g Lithium, Na valproate, carbamazepine, lamotrigine
Benzodiazepine can be used to help manage patient by getting them to relax & sleep.
Mood stabilisers - lithium has the strongest evidence to ↓ suicides. Stopping lithium has a high risk of relapse.
Na valproate is teratogenic, avoid using in pregnancy.
How do we use mood stabilisers when patients experiences mania or depression?
Mania:
1. Antipsychotics
- SGA: olanzapine, quetiapine, risperidone
- FGA: haloperidol
2. Lithium
- 1st line for maintenance & suicide prevention
Depression:
1. Lithium
- 1st line for suicide prevention
2. Antipsychotics
- Quetiapine
- Olanzapine + fluoxetine
Dosing should always start low and titrate up.
What are the SE and ADR of mood stabilisers?
- Lithium
- Sodium valproate
- Carbamazepine
- Lamotrigine
Lithium - hypothyroidism, tremors, ECG changes* nausea*, weight gain, polyuria
Sodium valproate - ↓ platelet count, pancreatitis, weight gain, SJS/TEN
Carbamazepine - SLE / TEN
Lamotrigine - sedation & weight gain but less than the others
What are some DDIs of mood stabilisers?
- Lithium
- Sodium valproate
- Carbamazepine
- Lamotrigine
Lithium - Sodium, Thiazides, ACEi/ARBs, NSAIDs, Dehydration* (STAND). All the STAND drugs ↑ risk of Li toxicity.
Na valproate - DDI w lamotrigine
Carbamazepine - agranulocytosis w clozapine
Lamotrigine - DDI w Na valproate
How are the mood stabilisers cleared?
- Lithium
- Sodium valproate
- Carbamazepine
- Lamotrigine
Lithium - 100% cleared by kidney
Na valproate - hepatically cleared
Carbamazepine - hepatically cleared, induces its own metabolism
Lamotrigine - hepatically cleared, clearance is impaired if taken with valproate
