Mania & Bipolar Disorder

Question 1

What is hypomania?

Answer 1

The mood is mildly elevated or unstable/irritable to a degree that is definitely abnormal but MILD for the individual concerned and lasts for at least four consecutive days.
At least three of the following must be present, that interferes with personal functioning but not to the extent that they lead to severe disruption of work or result in social rejection :
(1) increased activity or physical restlessness
(2) increased energy;
(3) increased talkativeness;
(4) difficulty in concentration/ distractibility;
(5) decreased need for sleep;
(6) increased sexual energy;
(7) mild spending sprees, or other types of mildly reckless or irresponsible behaviour
(8) increased sociability or over-familiarity.
The disturbances of mood and behaviour are not accompanied by hallucinations or delusions. Usually also see marked feelings of well-being and both physical and mental efficiency.

Question 2

What drugs are considered “mood stabilizers”

Answer 2

lithium, sodium valproate, carbamezapine, lamotrigine, quetiapine, aripiprazole, olanzapine

Question 3

What are the indications for mood stabilisers

Answer 3

Prophylaxis for bipolar disorder (i.e. to prevent relapse)
- Single manic episode associated with significant risk
- Illness with significant impact on functioning
- Two or more acute episodes
Treatment of an acute mania/hypomania
- Generally not first line
Treatment of bipolar depression
- Augmentation for antidepressants in treatment-resistant depression

Question 4

MOA and Indications of Lithium?

Answer 4

MOA unclear
Indicated in: Acute mania/hypomania (good evidence), Prophylaxis (to prevent relapse) in bipolar disorder, Bipolar depression, Treatment-resistant depression
Huge efficacy in reducing suicide attempt and completion risk

Question 5

What monitoring is required for lithium?

Answer 5

Thyroid function, Kidney function (6monthly)

lithium levels- 3 monthly

Question 6

What is “Ebstein’s anomaly” and what is it caused by?

Answer 6

this is a congenital abnormality of the tricuspid valve due to lithium exposure in utero in the first trimester.

Question 7

What are the indications of valproate? What are the cautions and counselling instructions
for valproate?

Answer 7

• Acute mania/hypomania
• Prophylaxis (to prevent relapse) in bipolar disorder (second line to lithium)

Counselling: For all women of child bearing potential it MUST be prescribed with a reliable contraceptive e.g. mirena coil because valproate is teratogenic. It is recommended that valproate is removed before conception. Valproate is associated w/ a number of adverse outcomes: autism, neural tube defects, congenital malformations, low verbal IQ, valproate syndrome- cleft lip/palate, spina bifida, limb malformations, genital abnormalities e.g. hypospadias, undescended testes (Cryptorchidism)

Question 8

What are the SE, pharmacodynamics and Cautions for Lithium?

Answer 8

Narrow T window= titration and monitoring v imp
Common SE: fine tremor, GI upset, polyuria, polydipsia- excessive thirst, metallic taste in mouth, weight gain, oedema
Causes of toxicity: low sodium diet, dehydration, interactions with other meds e.g. NSAIDs, ACEI, Loops, Thiazides, Addison’s
Symptoms of Toxicity: diarrhoea, nystagmus, coarse tremor, dysarthria, convulsions, confusion.
May require E admission for Haemodialysis
Cautions: Known teratogen- major congenital malformations in 6% of cases therefore withdraw prior to conception. primarily causes cardiac defects ie VSDs/ASDs. Imp association is tricuspid valve defect “Ebstein’s anomaly” due to lithium exp in first trimester. Also caution in breast feeding due to risk of lithium toxicity in bebe.

Question 9

What are the indiciations for lamotrigine? What are the SE and cautions for Lamotrigine?

Answer 9

Epilepsy, Bipolar depression, Prophylaxis (to prevent relapse) in bipolar disorder (limited evidence), Augmentation of antidepressants in treatment-resistant depression
SE: must be titrated slowly bc of concern of Stevens-Johnson syndrome- Type IV (subtype C) hypersensitivity reaction that typically involves the skin and the mucous membranes. A minor form of toxic epidermal necrolysis, with less than 10% body surface area detachment. otherwise generally well tolerated. Less teratogenic than lithium or valproate but is associated with increased risk of cleft lip/ palate if exposure during trimester 1.

Question 10

What is the MOA of carbamezapine? What is it indicated for?

Answer 10

Inhibits voltage gated Na+ channels in post synaptic neurone which reduces ability of high freq repetitive neurone firing, decreasing synaptic transmission.
Indications: Epilepsy, Acute mania/hypomania (weaker evidence than lithium or valproate), Prophylaxis in bipolar disorder (weak evidence), Bipolar depression

Question 11

What is the criteria for diagnosing mania?

Answer 11

Symptoms must be present for at least one week or are so severe to require hospital admission.
1) mood is elevated, expansive, irritable- it is incongruent with patient’s circumstances and may vary from carefree joviality to almost uncontrollable excitement
2) increased activity
3) reckless behaviour
4) disinhibition
5) marked distractibility
6) marked increase in sexual energy
7) sleep severely impaired/ absent
8) Grandiosity
9) flight of ideas
Mania can be w/ or w/o psychotic symptoms. If psychotic symptoms are present they may be grandiose delusions, second person hallucinations (and mood congruent) , motor excitement or flight of ideas so extreme and diff to follow. Most often the psychotic symptoms are “mood congruent” i.e. inflated self-esteem results in grandiose delusions, whereas irritable - persecutory delusions. Up to 10% manic patients w/ psychotic symptoms will have first rank symptoms.

Question 12

If a patient presents with one episode of mania and one of depression, what is their dx?

Answer 12

Bipolar affective disorder

Question 13

If a patient presents with two episodes of mania, what is their dx?

Answer 13

Bipolar affective disorder

Question 14

If a patient presents with one episode of mania, what is their dx?

Answer 14

Acute Mania

Question 15

What are the organic causes of Bipolar Disorder?

Answer 15

substance misuse (including steroids), hyperthyroidism (very severe), space-occupying lesion (especially frontal lobe), metabolic disorders, epilepsy

Question 16

What level of care is usually required for patients with Bipolar Disorder?

Answer 16

secondary mental health services, e.g. community mental health team, crisis team, early intervention in psychosis (EIP). Inpatient admission may be indicated. Assessment is commonly done under MHA.

Question 17

What is the epidemiology and aetiology of Bipolar Disorder?

Answer 17

1% lifetime risk. Onset primarily in late teens, early 20s. equal M:F
Genetics: increased risk if relatives have BP disorder
Environmental: prolonged stress / “vulnerability factors” predispose or ppt BP
Substance misuse: thought to be imp ppt.

Question 18

Prognosis of Bipolar Disorder

Answer 18

Av length of manic episode 6m (tx or untx) - remember this is an imp distinguishing factor from emotionally unstable PD- in this disorder, emotions fluctuate much more suddenly.
Following manic episode 90% will go on to have further mood disturbance.
patients usually recover well from an episode however, less than 20% achieve 5 years of clinical stability, with good social/occupational performance
People with bipolar disorder are around 20-30 times more likely to die by suicide than are the general population

Question 19

What are the 3 phases of bipolar disorder?

Answer 19

Acute manic phase
Bipolar depressive phase
Bipolar in remission but requires prevention of relapse (or sometimes called maintenance phase)

Question 20

What is first line tx for acute mania?

Answer 20

Haloperidol, olanzapine, risperidone or quetiapine are all appropriate first-line treatments for acute mania, and are recommended by NICE for this purpose.