Maladie Affective Bipolaire

Question 1

what is the estimated lifetime prevalence of illness across bipolar I, II and subthreshold bipolar disorder subtypes according to the world mental health survey

Answer 1

2.4%

(1.5% 12 month prevalence)

Question 2

what is the lifetime prevalence of bipolar I

Answer 2

0.6%

(0.4% 12 month prevalence)

Question 3

what is the lifetime prevalence of bipolar II

Answer 3

0.4%

(0.3% 12 month prevalence)

Question 4

what are the 3 “age of onset” age ranges for BDI

Answer 4

early onset (large/42%)–> around age 17 +/- 3 years

middle onset (smaller/26%)–> 24 years +/- 5 years

late onset (34%)–> 32 +- 12 years

Question 5

what comorbid conditions/symptoms are associated with earlier age of onset

Answer 5

longer delay to treatment

greater depressive severity

higher levels of anxiety and substance use

Question 6

in which cases should organic mania be considered and investigated

Answer 6

when mania onset occurs after age 50

(though manic episodes can occur for first time after age 50)

Question 7

for what % of the time are people with BD generally unable to maintain proper work role function

Answer 7

about 30% of the time or mroe

Question 8

why do we are about preventing mood episodes in BD

Answer 8

because on average the risk of recurrence increases with # of previous episodes

also–> number of previous episodes is associated with increased duration and symptomatic severity of subsequent episodes

also–> number of episodes is associated with lower threshold for developing further episodes

also–> increased risk of dementia with more episodes

Question 9

what are the three broad clinical stages in the staging system for BD

Answer 9

1. individuals at increased risk for developing BD due to family history as well as certain subsyndromal symptoms predictive of conversion to full BD
2. patients with fewer episodes and optimal functioning in interepisodic periods
3. patients with recurrent episodes as well as decline in functioning and cognition

*heterogeneity in BD has prevented clinical use of staging systems

Question 10

list 10 features of depression that may increase suspicion of bipolarity

Answer 10

1. earlier age of illness onset
2. highly recurrent depressive episodes
3. family history of BD
4. depression with psychotic features
5. psychomotor agitation
6. atypical depressive symptoms
   –hypersomnia
   –hyperphagia
   –leaden paralysis
7. postpartum depression and psychosis
8. past suicide attempts
9. antidepressant induced manic symptoms
10. rapid cycling

Question 11

what is the second most common misdiagnosis for BD

Answer 11

schizophrenia and other psychotic disorders –> occurs as initial diagnosis in asm any as 30% of patients

Question 12

what is a good screening tool for flagging patients who may have signs/symptoms of BD

Answer 12

the Mood Disorders Questionnaire (MDQ)

this is a validated self report instrument

Question 13

what % of identified patients with BD die by suicide

Answer 13

6-7%

Question 14

what % of patients with BD worldwide report SI

Answer 14

43%

21% have plan

Question 15

what % of patient with BD have attempted suicide in the past year worldwide

Answer 15

16%

Question 16

list 9 factors that have been significantly associated with suicidal ATTEMPT in BD

Answer 16

1. female sex
2. younger age of illness onset
3. depressive polarity of first illness episode
4. depressive polarity of current or more recent episode
5. comorbid anxiety disorder
6. comorbid SUD
7. comorbid cluster B/borderline PD
8. first degree family history of suicide
9. previous suicide attempts

Question 17

what are the only two risk factors that have been significantly associated with suicide DEATHS in BD

Answer 17

1. male sex
2. first degree family history of suicide

*older age also results in a higher degree of lethality of attempts with higher ratio of death:attempts

Question 18

what % of suicides in BD occur DURING an inpatient stay

Answer 18

14%

Question 19

what % of suicides in BD occur within 6 weeks of discharge

Answer 19

26%

Question 20

for which psychosocial interventions is there positive evidence in the maintenance phase of BD

Answer 20

CBT (2nd line)

family focused therapy (2nd line)

interpersonal and social rhythm therapy (3rd line)

peer support (3rd line)

Question 21

what psychosocial intervention is first line in maintenance phase of BD

Answer 21

psychoeducation

Question 22

how many sessions of individual psychoeducation would be required to be a first line intervention for relapse prevention in BD?

Answer 22

at least 5 sessions

level 2 evidence for relapse prevention

Question 23

is CBT recommended in acute bipolar depression

Answer 23

yes–> second line–> level 2 evidence

Question 24

how does interpersonal and social rhythm therapy differ from IPT

Answer 24

includes regulation of social and sleep rhythms specifically targeted to the bipolar population

24 individual sessions over 9 months

Question 25

what is the DSM V definition of agitation

Answer 25

"excessive motor activity associated with feeling of inner tension"

Question 26

list the 4 first line agents recommended for management of agitation in BD

Answer 26

aripiprazole IM (9.75 mg) lorazepam IM (2mg) loxapine inhaled (5mg) olanzapine IM (2.5mg)

Question 27

list 6 second line agents (or combinations) recommended for managing agitation in mania

Answer 27

asenapine haloperidol IM haloperidol + midazolam haloperidol + promethazine risperidone ziprasidone

Question 28

should monotherapy be tried before combination therapy?

Answer 28

not necessarily--> treating clinician makes the decision for mono or combo therapy *based on rapidity of response needed, whether hx previous partial response to monotherapy, severity of mania, tolerability concerns with combo therapy and willingness of patient to take combo therapy

Question 29

which works faster for acute mania, mono or combo therapy

Answer 29

combo

Question 30

List the 4 first line combination therapies for acute mania IN ORDER

Answer 30

1. Quetiapine + lithium/divalproex 2. Aripiprazole + lithium/divalproex 3. Risperidone + lithium/divalproex 4. Asenapine + lithium/divalproex

Question 31

list second line treatments (combo + mono) for acute mania IN ORDER

Answer 31

1. olanzapine 2. carmabazepine 3. olanzapine + lithium/divalproex 4. lithium + divalproex 5. ziprasidone 6. haloperidol 7. ECT

Question 32

what is a mnemonic for second line treatments for acute mania

Answer 32

Only Cows On LSD Zipline Happily Evermore

Question 33

with which treatment for acute mania is there a concern for depressive switch

Answer 33

haldol

Question 34

which first line treatments for acute mania have data for treating acute depression as well

Answer 34

lithium quetiapine divalproex cariprazine

Question 35

which first line treatments for acute mania have data for preventing depression

Answer 35

lithium quetiapine divalproex asenapine

Question 36

which first line agents for treatment of acute mania have evidence for preventing mania

Answer 36

all EXCEPT cariprazine

Question 37

which first line agent for acute mania has the most tolerability concerns in the acute period

Answer 37

quetiapine

Question 38

which first line agents for acute mania (3) have the most safety concerns in the maintenance period

Answer 38

lithium quetiapine divalproex

Question 39

which first line combination therapies for acute mania have the most safety concerns in the maintenance period

Answer 39

quetiapine + lithium/divalproex risperidone + lithium/divalproex *significant impact on treatment selection

Question 40

which combination therapy for acute mania seems to have the best tolerability and safety profile in the maintenance period

Answer 40

asenapine + lithium/divalproex *but this is also ranked fourth in the combo ranking the next safest/most tolerable is aripiprazole + lithium/divalproex followed by the quetipaine and risperidone combos

Question 41

does ziprasidone treat and/or prevent bipolar deprssion

Answer 41

no data for prevention data shows it does NOT treat bipolar depression

Question 42

does ECT treat and/or prevent bipolar deprssion

Answer 42

it seems to do both (level 4 evidence)

Question 43

does haloperidol treat and/or prevent bipolar deprssion

Answer 43

data suggests it does NOT prevent no data with regard to treating bipolar depression

Question 44

when should efficacy of treatment for acute mania be evaluated

Answer 44

at the end of weeks 1 and 2 and then treatment options modified accordingly

Question 45

what % of patients presenting with acute mania will respond to monotherapy? in what time frame?

Answer 45

50% within 3-4 weeks

Question 46

how does efficacy compare in acute mania treatment between the first line monotherapy agents

Answer 46

comparable efficacy

Question 47

for those initiating or switching treatments during the maintenance phase, which medications would be considered FIRST line for this phase of bipolar disorder

Answer 47

lithium divalproex lamotrigine asenapine aripiprazole (monotherapy or in combination)

Question 48

after how long did almost all anti-manic agents separate from placebo in trials

Answer 48

after one week therefore, expect some therapeutic response to antimanic agents within 1-2 weeks

Question 49

which first line anti manic agents that are recommended for monotherapy are NOT recommended for combination therapy

Answer 49

paliperidone and ziprasidone due to lack of evidence for additional efficacy

Question 50

what % of patients is it estimated will respond to ECT as antimanic treatment

Answer 50

up to 80%

Question 51

what non-AP or mood stabilizer has level 2 evidence for treatment of acute mania and is third line

Answer 51

tamoxifen (downgraded because of the risk of uterine cancer and lack of clinical experience DESPITE EVIDENCE FOR EFFICACY)

Question 52

what neurostimulation therapy, other than ECT, can be considered as third line in treatment of acute mania

Answer 52

rTMS

Question 53

name a non pharmacologic intervention that has level 3 evidence for treatment of acute mania when combined with other anti manic agents

Answer 53

glasses that block blue light

Question 54

when would you usually choose divalproex over lithium when treating mania

Answer 54

1. person has multiple prior episodes 2. predominant irritable or dysphoric mood 3. comorbid substance use and/or 4. those with hx head trauma

Question 55

does the presence of anxious distress during a manic episode give any prognostic information

Answer 55

yes--> predictor of poor outcome i.e greater severity of manic symptoms, longer time to remission, more reported side effects of medication

Question 56

are there specific agents recommended to treat anxious distress is mania

Answer 56

not studies specifically examining this--> anxious distress tends to improve as the mood episode improves post hoc analyses: divalproex quetiapine olanzapine may be helpful

Question 57

what % of manic episodes are characterized by the presence of psychosis

Answer 57

at least HALF

Question 58

does it matter whether psychotic symptoms are mood congruent or incongruent in BD

Answer 58

if psychosis is mood incongruent seem t have more severe illness with poorer long term prognosis

Question 59

is there any evidence of superiority of any first line antimanic monotherapy compared to any other when psychotic features are present?

Answer 59

no also no evidnece that any particular combo therapy is better for psychotic features **clinical experience suggests combo therapy of atypical AP + li/dvp more appropriate for manic patients with mood-incongruent psychotic features

Question 60

what % of patients with bipolar I have rapid cycling BD

Answer 60

about 30%

Question 61

what three other factors are often associated with rapid cycling in BD

Answer 61

hypothyroidism antidepressant use substance use