Mania and bipolar disease Flashcards
what is mania?
Mania:
Abnormally elevated mood, unwarranted optimism, exuberance, over-confidence, inflated self-esteem, hyperactivity, excessive libido and little sleep
Increased drive and extrovert behaviour but often socially tactless
Makes compliance problematic
Attack lasts a week or more
Almost invariably goes hand-in-hand with episodes of severe depression, hence older term of manic-depressive disorder, now bipolar disorder (or bipolar affective disorder) for repeated episodes of mania (or hypomania) and depression
Depressive periods last longer than manic episodes
Variable periods of normal behaviour between episodes of mania and depression.
Classification: ICD-11 (or DSM-5) criteria used to define
Bipolar I disorder = more severe mania
Bipolar II disorder = hypomania (mania less severe)
what is the symptoms of mania?
diagnosis
Abnormally elevated mood, extreme irritability, and sometimes aggression
Increased energy or activity, restlessness, and decreased need for sleep
Pressure of speech or incomprehensible speech
Flight of ideas or racing thoughts
Distractibility, poor concentration
Increased libido, disinhibition, and sexual indiscretions
Extravagant or impractical plans (for example business investments, spending sprees)
Psychotic symptoms: delusions (usually grandiose) or hallucinations (usually voices)
Diagnosis of a manic episode requires symptoms of mania lasting for at least 7days which usually begin abruptly
what is hypomanias symptoms?
diagnosis
Hypomania is suggested bysymptoms of mania that are not severe enough to cause marked impairment in social or occupational functioning, and the absence of psychotic features.
> Diagnosis of a hypomanic episode requires symptoms to last for at least 4days
A mixed episodeis suggested bya mixture, or rapid alternation (usually within a few hours), of manic/hypomanic and depressive symptoms.
Depressionis suggested byfeelings of persistent sadness or low mood, loss of interest or pleasure, and low energy.
how does the diagnosis of bipolar disease work?
Detection of bipolar disorder in people presenting with depressive symptoms may be improved by asking about a history of overactive, disinhibited behaviour lasting 4 days or more.The following questions may be useful:
‘Do you currently (or have you in the past) experienced mood that is higher than normal, or do you feel much more irritable than usual, and have others noticed?’
‘At the same time, do you have increased energy levels so that you are much more active or do not need as much sleep?’
These are based on expert opinions in e.g. DSM-V, ICD10 and other sources. Definitive diagnosis should be made via referral to specialist mental health services
what is the management of BPD?
No known cause though some evidence of genetic/environmental links (70% concordance in identical twins). Strong genetic component.
Aims of treatment:
Control manic and depressive attacks
Minimise recurrence and stabilise mood
Control manic attacks typically with sedative anti-psychotics (atypicals)
what is the propylaxis of BPD?
Prophylaxis for long-term treatment including mood stabilising drugs and psychological interventions (e.g. CBT). Mood stabilisers include:
Lithium (common, long-term mood stabiliser but not immediately effective)
Anticonvulsants, particularly Sodium valproate* (can help manage manic phases)
Prophylaxis may also include:
Other anticonvulsants used such as lamotrigine and carbamazepine
Some atypical antipsychotics e.g. olanzapine or quetiapine
Antidepressants not typically used or if used are in combination
Benzodiazepines may be used short-term for mania (for MoA, Lecture 3)
what is the Treatments for Mania and BPD
Lithium (carbonate) for acute mania or bipolar disorder and BPD prophylaxis
BUT – very narrow therapeutic window, needs careful monitoring
Blood monitoring – typically 0.6-0.8mmol/L (may have therapeutic effect at 0.4 or may need up to 1.0
Toxic at >1.5mmol/L but can have toxicity at lower (therapeutic) doses
Sustained release formulations help avoid high peak plasma concentrations
Takes 2-3 weeks to have effect
Many side effects can include renal, endocrine, cardiac, neurological – reduced by lowering dose
Drug interactions can affect levels (NSAID, diuretics, ACE inhibitors)
MoA not fully understood, may include neuroprotection, modulation of neurotransmission, inhibition of GSK-3B or reduction of Inositol
MONITOR thyroid and kidney function (and check CVS, renal and thyroid before commencing)
Antipsychotics (Atypicals, D2 antagonists and other mechanisms/targets)
Can give control of mania and some help to prevent relapse/mood stabiliser
Commonly atypicals such as olanzapine, quetiapine, risperidone (haloperidol is first generation/typical). Common side effects such as weight gain, sedation, hyperglycemia, anticholinergic). Other 2nd gen. atypicals may be used in mania and/or BPD e.g., aripiprazole (treatment mania and prevention recurrence) or asenapine (sublinguial tablet, mod-sev manic episodes) – e.g., less risk weight gain and low anticholinergic effects
Antiepileptic/anticonvulsants MoA not fully understood. Typically Na+ channel blockers that decrease AP firing (also putative action on other NT signalling)
Valproate* – mania and prophylaxis of bipolar disorder (possible effects at voltage-gated sodium channels, GABA signalling, and others)
Carbamazepine – prophylaxis of bipolar patients unresponsive to lithium, may be used for mania
Lamotrigine – prophylaxis of bipolar disorder (and depression, not mania)
Significant cognitive side effects
Primary care versus secondary care
Initial mania treatment usually in secondary care (or in primary care with advice from specialist): options include atypical antipsychotics such as olanzapine, quetiapine, risperidone, or (typical) haloperidol
Baseline monitoring and subsequent monitoring depending on treatment*
If ineffective a second may be tried before adding lithium or sodium valproate (if lithium is unsuitable)
If already taking antidepressants usually tapered and discontinued
For depression in this period treatment options include e.g. Quetiapine alone,or Fluoxetine + olanzapine,or Olanzapine alone,or Lamotrigine alone
Four weeks after resolution of acute episode establish long-term plan. Can include staying on current mania treatment or e.g. lithium (common) to prevent relapse with/without second agent
Specific psychological therapy may also be offered
If stable, a patient treated in secondary care may continue management in primary care (usually after at least 12 months)
lithium
use
side effects ?
Lithium (carbonate) for acute mania or bipolar disorder and BPD prophylaxis
BUT – very narrow therapeutic window, needs careful monitoring
Blood monitoring – typically 0.6-0.8mmol/L (may have therapeutic effect at 0.4 or may need up to 1.0
Toxic at >1.5mmol/L but can have toxicity at lower (therapeutic) doses
Sustained release formulations help avoid high peak plasma concentrations
Takes 2-3 weeks to have effect
Many side effects can include renal, endocrine, cardiac, neurological – reduced by lowering dose
Drug interactions can affect levels (NSAID, diuretics, ACE inhibitors)
MoA not fully understood, may include neuroprotection, modulation of neurotransmission, inhibition of GSK-3B or reduction of Inositol
MONITOR thyroid and kidney function (and check CVS, renal and thyroid before commencing)
examples of Antipsychotics
moa
use
Atypicals, D2 antagonists and other mechanisms/targets)
Can give control of mania and some help to prevent relapse/mood stabiliser
Commonly atypicals such as olanzapine, quetiapine, risperidone (haloperidol is first generation/typical). Common side effects such as weight gain, sedation, hyperglycemia, anticholinergic). Other 2nd gen. atypicals may be used in mania and/or BPD e.g., aripiprazole (treatment mania and prevention recurrence) or asenapine (sublinguial tablet, mod-sev manic episodes) – e.g., less risk weight gain and low anticholinergic effects
example of Antiepileptic/anticonvulsants
moa
use
Antiepileptic/anticonvulsants MoA not fully understood. Typically Na+ channel blockers that decrease AP firing (also putative action on other NT signalling)
Valproate* – mania and prophylaxis of bipolar disorder (possible effects at voltage-gated sodium channels, GABA signalling, and others)
Carbamazepine – prophylaxis of bipolar patients unresponsive to lithium, may be used for mania
Lamotrigine – prophylaxis of bipolar disorder (and depression, not mania)
Significant cognitive side effects
what is valporate used for?
mania and prophylaxis of bipolar disorder (possible effects at voltage-gated sodium channels, GABA signalling, and others)
what is carbamazepine used for?
prophylaxis of bipolar patients unresponsive to lithium, may be used for mania
what is lamotrigine used for?
prophylaxis of bipolar disorder (and depression, not mania)
Significant cognitive side effects
