Pharmacotherapy of Bipolar Disorders Flashcards
Bipolar Disorders
- Bipolar I Disorder: Mania (and usually major depression)
- Bipolar II Disorder: Hypomania and Major Depression
- Cyclothymic Disorder: subthreshold hypomania and subthreshold depression
- Substance/Medication Induced Bipolar Disorder
- Bipolar Disorder due to another medical condition
Mania
- Distinct period
- Abnormal and persistent
- Elevated, expansive, or irritable mood
- Increased activity or energy
- 1 Week (or any duration if hospitalization needed)
- Most of the day nearly every day
Mania Symptoms
- Inflated self-esteem or grandiosity
- Decreased need for sleep
- More talkative than usual/pressured speech
- Flight of ideas/racing thoughts
- Distractability
- Increased goal directed activity
- Excessive involvement in high risk activity: buying sprees, sex, foolish investments
- Marked impairment or hospitalization or psychosis
- Exclude other causes
Hypomania
Mania Criteria Except
- 4 days
- Unequivocal change in functioning
- Observable by others
- Not severe enough to cause impairment or hospitalization
- No psychosis
Specifiers
- Rapid Cycling: 4 or more distinct mood episodes per year
- Mixed Features: presence of depressive symptoms in mania or vice versa
- With Psychotic Fetures
- With Anxious Distress
- Seasonal Pattern
- Peripartum Onset
Screening for Bipolar Disorders
- MDQ >= 7 (Sensitivity 58%, Specificity 93%)
- Self Report Scale
- > =7 symptoms occuring at same time
- Moderate or serious
Acute Phase Treatment Goals
- 1-3 months
- Non-response: <25% reduction in symptoms
- Partial Response: 25-50% reduction in symptoms
- Response: >50% reduction in symptoms
- Remission: Absence of mood symptoms for over 2 months
Maintenance Phase Treatment Goals
- 3 months - lifetime
- Prevent relapse to any mood episode
Bipolar Disorder Treatments
- Bipolar Mania: Medication SMD 0.42
- Bipolar Depression: Medication SMD 0.24
- Bipolar Maintenance: Medication SMD 0.41
- Psychotherapy: not for monotherapy, possibly effective for augmentation
First Generation Antipsychotics (D2 Antagonist)
- High Potency: Haloperidol*, Fluphenazine
- Mid Potency: Perphenazine
- Low Potency: Chlorpromazine, Thioridazine*
Second Generation Antipsychotics (D2/5HT2 Antagonist)
- High Potency: Risperidone, Olanzapine, Asenapine, Paliperidone, Iloperidone
- Mid Potency: Ziprasidone*, Lurasidone
- Low Potency: Quetiapine, Clozapine
Second Generation Antipsychotics (D2 Partial Agonist/5HT2 Antagonist)
- Aripiprazole
- Brexpiprazole
- Cariprazine
Theories of Atypicality
- Minimal Neuroleptic Potential: Clozapine, Quetiapine
- 5HT2 Antagonism/D2 Disinhibition: all second generation
- Fast Off/Kiss-and-Go: Clozapine, Quetiapine, Olanzapine
- D2 Partial Agonism: Aripiprazole, Brexpiprazole, Cariprazine
Antiepileptics
- Valproic Acid/Divalproex 25-60 mg/kg/day
- Carbamazepine 400-800 mg PO BID
- Lamotrigine 200 mg PO QD
Monitoring
- Baseline: CBC, Chem7, LFTs, lipase, HCG
- Follow-up: Troughs and the baselines
Lithium
- 900-1800 mg/day
- Conduction blocks, delirium, ataxia, coma, seizures, death at toxicity
Monitoring
- Baseline: Chem7, Ca+, TSH, HCG
- Follow-up: Baselines and trough levels
Strong Suicide Risk Factors
- History of attempts
- Age >65 y.o.
- <5 years since psychiatric hospital discharge
- Severe pain
Moderate Suicide Risk Factors
- Access to firearms
- PHQ-9 question 9
- Prior psychiatric hispitalization
- High dose benzos
- Hopelessness
- Seizure disorder
- Alcohol abuse
- Manic depressive disorder
- Family history of suicide
Weak Suicide Risk Factors
- Depressive disorder
- Anxiety disorder
- CHF
- COPD
- Moderate pain
- Ever prescribed a benzo
- Male sex
- White race
Ideal Mood Stabilizer
- Treats all phases of bipolar disorder
- Includes acute mania/depression and maintenance
Ideal Mood Stabilizer Examples
- Olanzapine/Fluoxetine
- Olanzapine
- Quetiapine
- Valproate
- Lithium + Valproate
- Lithium (?)
- ECT (probably)
Antiepileptics + Lithium
- Inhibits phosphoinositide hydrolysis
- Inhibits glycogen synthase kinase
- Inhibits histone deacetylases
- Decreases PKC Activity
- Facilitates GABA transmission
Bipolar Depression Treatments
- Olanzapine/Fluoxetine
- Valproate
- Quetiapine
- Lurasidone
- Olanzapine
Off-Label
-Augmentation of mood stabilizer: Armodafinil or pramipexole
Weight Gain + Antipsychotics
- Olanzapine
- Gabapentin
- Amitriptyline
- Mirtazapine
- Quetiapine
- Risperidone
Weight Loss + Antipsychotics
- Topiramate
- Buproprion
- Fluoxetine