Psychobiology of Bipolar Flashcards
Define Bipolar disorder (BPD)
Cyclic disorder, recurrent fluctuations in mood, episodes of mania and deperssion persist for months without treatment.
Euthymia
The normal fluctuations of highs and lows
Dysthymia
A depressed episode that does not meet the full criteria for a depressed episode
Mania
the most florid expression of elevated mood
Hypomania
Elevated mood that does not meet the full criteria for a manic episode
Cyclothymia
Mood swings that are larger than the normal fluctuations of mood but do not meet criteria for the extremes
What common perception of bipolar is there that is completely wrong?
That people cycle quickly. Many people have only four episodes during the first ten years of their life and may have normal moods in between.
Bipolar I disorder defined
patients experience manic or mixed episodes and USUALLY depressive episodes too, but not always (often called unipolar mania. No attic sometimes no basement.
Bipolar II disorder defined
Patients experience hypomanic or depressive episodes but NOT manic or mixed episodes. Some attic, no basement “sunken cyclothymia”
Although there is very little known about bipolar its causes in the neural system what has been recently found?
decreased connectivity between the amygdala and anterior cingulate cortex. and increased connectivity between the amygdala and the supplemental motor area.
What effect does Lithium have that valporic acid does not?
Lithium has been shown to stimulate BDNF synthesis which then shows increases in total gray matter volume.
What are non pharmacologic interventions for bipolar?
Education, psychotherapy, and LAST resort electroconvulsive therapy (symptoms that are life threatening only)
Which two drugs are preferred for acute management of manic episodes?
Lithium and Valporic acid
The only type of mania in which Lithium is the preferred choice?
Euphoric mania
If a patient has just started on lithium or valproate and they need help with symptoms such as insomnia, anxiety, and/or agitation until the mood stabilizer for mild mania takes full effect what can be done?
benzodiazepine such as Ativan may be adequate
If a patient has just started on lithium or valproate and they need help with symptoms such as insomnia, anxiety, and/or agitation until the mood stabilizer for major mania takes full effect what can be done?
Antipsychotic such as olanzapine or risperidone are good choices
Short term therapy for mania is?
antiepileptic mood stabilizer such as lithium or valporate
Short term therapy for depressive episodes?
mood stabilizer alone or mood stabilizer plus an antidepressant
Why should you never treat bipolar depressive episodes with an antidepressant alone?
Because hypomania or mania may result
What are the preferred antidepressants to be used in conjunction with a mood stabilizer?
bupropion, venlafaxine, or an SSRI
What are long term pharmacological treatment options for treating bipolar?
If patient responded to acute therapy with lithium alone, then they should try lithium long term. Other long term options include valproate alone, and valproate plus lithium. Antipsychotic agents can be tried either as monotherapy or in combination with a mood stabilizer.
What is Lithium used for?
BPD, alcoholism, bulimia, schizophrenia, and glucocorticoid induced psychosis
Lithium is excreted by
rapidly by the renal system
How must lithium be administered?
in divided daily doses due to its short half life and high toxicity
Lithium excretion is reduced when?
sodium levels are low. Patients MUST maintain an adequate sodium intake otherwise the body will retain lithium and cause toxicity
What medications can cause sodium loss and therefore should be employed with great caution when a patient is on lithium?
diuretics
What two things should someone taking lithium be cautious of due to the potential for dehydration and resultant lithium toxicity?
hot weather and diarrhea
What should lithium levels be at for initial therapy of a manic episode?
0.6 to 1.2 mEq/L
When the desired therapeutic effects with lithium have been achieved what should the lithium levels be?
reduced to 0.4 to 1 mEq/L
What is considered lithium toxicity?
greater than 1.5
When should lithium blood draws be done?
In the morning, twelve hours after the evening dose. During maintenance therapy levels should be measured every 3 to 6 months.
What toxicities are associated with a lithium level that is still less than 1.5?
nausea, vomiting, diarrhea, thirst, polyuria, lethargy, slurred speech, muscle weakness, fine hand tremor
What toxicities are associated with a lithium level that is 1.5-2
persistent GI upset, coarse hand tremor, confusion, hyperirritability of muscles, ECG changes, sedation, incoordination
What toxicities are associated with a lithium level that is 2-2.5?
Ataxia, giddiness, high output of dilute urine, serious ECG changes, fasciculations, tinnitus, blurred vision, clonic movements, seizures, stupor, severe hypotension, coma, death
What toxicities are associated with a lithium level that is more than 2.5?
symptoms may progress rapidly to generalized convulsions, oliguria, and death
What drug interactions are there with Lithium?
diuretics, NSAIDS (increase lithium levels by as much as 60%), Anticholinergics (urinary hesitancy coupled with lithium polyuria is uncomfortable includes antihistamines, phenothiazine, antipsychotics, TCAs)
What are the only two NSAIDS that do NOT affect lithium blood levels?
aspirin, sulindac
What makes valproate better than lithium?
works faster, higher therapeutic index, and a more desirable side effect profile
What makes lithium better than valproate?
It is better at reducing the risk for suicide and more effective at preventing relapses
What are the three adverse effects associated with valproate toxicity?
thrombocytopenia, pancreatitis, and liver failure
What are common side effects of Valproate?
GI disturbances, weight gain, and is teratogenic
What is the dose of Carbamazepine for an acute manic episode?
200 mg twice a day
What is the maximum dose of Carbamazepine?
1600 mg/day
What is the target trough plasma level for carbamazepine?
4-12 mcg/mL
What side effect are common in early Carbamazepine treatment but generally resolve despite continued drug use?
Neurologic side effects such as visual disturbances, ataxia, vertigo, unsteadiness, and headache
What are some relatively uncommon side effects in Carbamazepine that can be very severe?
hematologic such as leukopenia, anemia, thrombocytopenia, aplastic anemia.
What medications does Carbamazepine accelerate the metabolism of?
Itself, oral contraceptives, warfarin, valproate, TCA
What is Lamotrigine indicated for?
Long term maintenance of BPD
What are potential side effects of Lamotrigine?
headache, dizziness, double vision, and rarely life threatening rashes such as Stevens-Johnson syndrome and Toxic epidermal necrolysis
What are the six atypical antipsychotics that are approved for short term BPD?
olanzipine (Zyprexa), quetiapine (seroquel) resperidone (Risperdal, aripriprazole (Abilify, cariprazine (Vraylar), and ziprasidone (Geodon)
What are the four atypical antipsychotics that are approved for long term treatment of BPD?
aripriprazole, olanzipine, quetiapine, ziprasidone
