Maladie Affective Bipolaire Flashcards
what is the estimated lifetime prevalence of illness across bipolar I, II and subthreshold bipolar disorder subtypes according to the world mental health survey
2.4%
(1.5% 12 month prevalence)
what is the lifetime prevalence of bipolar I
0.6%
(0.4% 12 month prevalence)
what is the lifetime prevalence of bipolar II
0.4%
(0.3% 12 month prevalence)
what are the 3 “age of onset” age ranges for BDI
early onset (large/42%)–> around age 17 +/- 3 years
middle onset (smaller/26%)–> 24 years +/- 5 years
late onset (34%)–> 32 +- 12 years
what comorbid conditions/symptoms are associated with earlier age of onset
longer delay to treatment
greater depressive severity
higher levels of anxiety and substance use
in which cases should organic mania be considered and investigated
when mania onset occurs after age 50
(though manic episodes can occur for first time after age 50)
for what % of the time are people with BD generally unable to maintain proper work role function
about 30% of the time or mroe
why do we are about preventing mood episodes in BD
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
what are the three broad clinical stages in the staging system for BD
- individuals at increased risk for developing BD due to family history as well as certain subsyndromal symptoms predictive of conversion to full BD
- patients with fewer episodes and optimal functioning in interepisodic periods
- patients with recurrent episodes as well as decline in functioning and cognition
*heterogeneity in BD has prevented clinical use of staging systems
list 10 features of depression that may increase suspicion of bipolarity
- earlier age of illness onset
- highly recurrent depressive episodes
- family history of BD
- depression with psychotic features
- psychomotor agitation
- atypical depressive symptoms
–hypersomnia
–hyperphagia
–leaden paralysis - postpartum depression and psychosis
- past suicide attempts
- antidepressant induced manic symptoms
- rapid cycling
what is the second most common misdiagnosis for BD
schizophrenia and other psychotic disorders –> occurs as initial diagnosis in asm any as 30% of patients
what is a good screening tool for flagging patients who may have signs/symptoms of BD
the Mood Disorders Questionnaire (MDQ)
this is a validated self report instrument
what % of identified patients with BD die by suicide
6-7%
what % of patients with BD worldwide report SI
43%
21% have plan
what % of patient with BD have attempted suicide in the past year worldwide
16%
list 9 factors that have been significantly associated with suicidal ATTEMPT in BD
- female sex
- younger age of illness onset
- depressive polarity of first illness episode
- depressive polarity of current or more recent episode
- comorbid anxiety disorder
- comorbid SUD
- comorbid cluster B/borderline PD
- first degree family history of suicide
- previous suicide attempts
what are the only two risk factors that have been significantly associated with suicide DEATHS in BD
- male sex
- first degree family history of suicide
*older age also results in a higher degree of lethality of attempts with higher ratio of death:attempts
what % of suicides in BD occur DURING an inpatient stay
14%
what % of suicides in BD occur within 6 weeks of discharge
26%
for which psychosocial interventions is there positive evidence in the maintenance phase of BD
CBT (2nd line)
family focused therapy (2nd line)
interpersonal and social rhythm therapy (3rd line)
peer support (3rd line)
what psychosocial intervention is first line in maintenance phase of BD
psychoeducation
how many sessions of individual psychoeducation would be required to be a first line intervention for relapse prevention in BD?
at least 5 sessions
level 2 evidence for relapse prevention
is CBT recommended in acute bipolar depression
yes–> second line–> level 2 evidence
how does interpersonal and social rhythm therapy differ from IPT
includes regulation of social and sleep rhythms specifically targeted to the bipolar population
24 individual sessions over 9 months
what is the DSM V definition of agitation
“excessive motor activity associated with feeling of inner tension”
list the 4 first line agents recommended for management of agitation in BD
aripiprazole IM (9.75 mg)
lorazepam IM (2mg)
loxapine inhaled (5mg)
olanzapine IM (2.5mg)
list 6 second line agents (or combinations) recommended for managing agitation in mania
asenapine
haloperidol IM
haloperidol + midazolam
haloperidol + promethazine
risperidone
ziprasidone
should monotherapy be tried before combination therapy?
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
which works faster for acute mania, mono or combo therapy
combo
List the 4 first line combination therapies for acute mania IN ORDER
- Quetiapine + lithium/divalproex
- Aripiprazole + lithium/divalproex
- Risperidone + lithium/divalproex
- Asenapine + lithium/divalproex
list second line treatments (combo + mono) for acute mania IN ORDER
- olanzapine
- carmabazepine
- olanzapine + lithium/divalproex
- lithium + divalproex
- ziprasidone
- haloperidol
- ECT
what is a mnemonic for second line treatments for acute mania
Only Cows On LSD Zipline Happily Evermore
with which treatment for acute mania is there a concern for depressive switch
haldol
which first line treatments for acute mania have data for treating acute depression as well
lithium
quetiapine
divalproex
cariprazine
which first line treatments for acute mania have data for preventing depression
lithium
quetiapine
divalproex
asenapine
which first line agents for treatment of acute mania have evidence for preventing mania
all EXCEPT cariprazine
which first line agent for acute mania has the most tolerability concerns in the acute period
quetiapine
which first line agents for acute mania (3) have the most safety concerns in the maintenance period
lithium
quetiapine
divalproex
which first line combination therapies for acute mania have the most safety concerns in the maintenance period
quetiapine + lithium/divalproex
risperidone + lithium/divalproex
*significant impact on treatment selection
which combination therapy for acute mania seems to have the best tolerability and safety profile in the maintenance period
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
does ziprasidone treat and/or prevent bipolar deprssion
no data for prevention
data shows it does NOT treat bipolar depression
does ECT treat and/or prevent bipolar deprssion
it seems to do both (level 4 evidence)
does haloperidol treat and/or prevent bipolar deprssion
data suggests it does NOT prevent
no data with regard to treating bipolar depression
when should efficacy of treatment for acute mania be evaluated
at the end of weeks 1 and 2 and then treatment options modified accordingly
what % of patients presenting with acute mania will respond to monotherapy? in what time frame?
50% within 3-4 weeks
how does efficacy compare in acute mania treatment between the first line monotherapy agents
comparable efficacy
for those initiating or switching treatments during the maintenance phase, which medications would be considered FIRST line for this phase of bipolar disorder
lithium
divalproex
lamotrigine
asenapine
aripiprazole
(monotherapy or in combination)
after how long did almost all anti-manic agents separate from placebo in trials
after one week
therefore, expect some therapeutic response to antimanic agents within 1-2 weeks
which first line anti manic agents that are recommended for monotherapy are NOT recommended for combination therapy
paliperidone and ziprasidone
due to lack of evidence for additional efficacy
what % of patients is it estimated will respond to ECT as antimanic treatment
up to 80%
what non-AP or mood stabilizer has level 2 evidence for treatment of acute mania and is third line
tamoxifen
(downgraded because of the risk of uterine cancer and lack of clinical experience DESPITE EVIDENCE FOR EFFICACY)
what neurostimulation therapy, other than ECT, can be considered as third line in treatment of acute mania
rTMS
name a non pharmacologic intervention that has level 3 evidence for treatment of acute mania when combined with other anti manic agents
glasses that block blue light
when would you usually choose divalproex over lithium when treating mania
- person has multiple prior episodes
- predominant irritable or dysphoric mood
- comorbid substance use
and/or
- those with hx head trauma
does the presence of anxious distress during a manic episode give any prognostic information
yes–>
predictor of poor outcome
i.e greater severity of manic symptoms, longer time to remission, more reported side effects of medication
are there specific agents recommended to treat anxious distress is mania
not studies specifically examining this–> anxious distress tends to improve as the mood episode improves
post hoc analyses:
divalproex
quetiapine
olanzapine
may be helpful
what % of manic episodes are characterized by the presence of psychosis
at least HALF
does it matter whether psychotic symptoms are mood congruent or incongruent in BD
if psychosis is mood incongruent seem t have more severe illness with poorer long term prognosis
is there any evidence of superiority of any first line antimanic monotherapy compared to any other when psychotic features are present?
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
what % of patients with bipolar I have rapid cycling BD
about 30%
what three other factors are often associated with rapid cycling in BD
hypothyroidism
antidepressant use
substance use
