Therapeutics - Bipolar disorder Flashcards
What is the aetiology of bipolar disorder?
Genetics
- Loci on genes and X-chromosome: 18, 11p15, 21
- 80-90% of bipolar pts hv biological relative w mood disorder
- 1st deg relative w bipolar pt: 5-10% risk (bipolar disorder), 15-35% risk (any mood disorder)
Drug induced
- Antidepressants: Dev bipolar mania (increased NE, DA transmission)
- DA augmenting agents (amphetamines, cocaine, sympathomimetics, DA agonists, releasers, reuptake inhib)
- NE augmenting agents (NE reuptake inhib, alpha-2 antagonists, beta agonists)
- steroids
- Thyroid preps
- xanthines
- OTC wt loss agents & decongestants
- St John’s Wort
Treatment
- ECT
- Bright light thera
General med conditions as per depression
Hx of trauma
Phsycial tressors e.g. sleep deprivation
Seasonal changes
What is bipolar disorder?
A cyclical mood disorder, alternating between episodes of mania and depression. As the disease progresses, the mood episodes become more frequent until there is no more normal mood.
What are the risk factors for bipolar disorder?
Antidepressants
Describe the epidemiology of bipolar disorder.
1.6% in SG
Peak age of onset 15-19y.o.
No racial/gender diff
Alc & sub use common (40-60%)
Mortality rate 2-3x higher than general pop
-15x more likely to commit suicide
What are the signs and symptoms of bipolar mania?
Hypomania >=4d, Full blown mania >=7d
At least 3 symptoms plus the elevated/expansive mood (or 4 symptoms if the mood is only irritable)
Distractability
Irresponsibility and erratic uninhib behaviour
Grandiosity
Flight of thoughts
Activity - increased, must be preoccupied
Sleep - decreased
Talkativeness - can’t interrupt them
What are the differential Dx assoc w Bipolar disorder?
Growing pains
ADHD, psychosis/schizo, personality disorders
MDD
Substance/med induced
What is the 1st episode presentation?
M: commonly manic, F: commonly depressive
60% of manic ep occur immediately before depressive ep
What are the signs and symptoms of bipolar depression?
Same as for MDD
Interest - decreased
Sleep - insomnia/hypersomnia
Appetite - >5-7% decreased from baseline
Depressed mood
Concentration - decreased
Activity - psychomotor agitation
Guilt
Energy - low
Suicidal thots or attempts
Describe the general principles of management for bipolar disorder.
Short course or prn benzodiazepines
For first 1-2weeks while waiting for mood stabilised to work, then will be discontinued.
Mood stabilised to be selected based on symptoms. Start on same day as benzodiazepines.
Describe the principles of management for bipolar mania.
1st line for maintenance & relapse/suicide prevention
Antipsychotics: SGA > FGA
Valproate: least preferred
Combi: Li and/or valproate +/- antipsychotic
Describes the principles of management of bipolar depression.
NEVER use antidepressants
Li
Antipsychotic (SGA): quetiapine XR or olanz+fluoxetine»lurasidone, cariprazine
Lamotrigine: doesnt cause wt gain or drowsiness. up titrate slowly (SJS risk)
Do not give valproate to females of childbearing potential
Li and valproate shld be ini by specialist
Lamotrigine does not treat mania
When do we refer for bipolar disorder?
When do we switch agents?
If mania is not resp within 2-4 weeks w an est 1st line mood stabiliser
- Augment w a second 1st line agent
- Switch to SGA
- Reserve CBZ for after failing above
What is the recommendation for bipolar disorder w rapid cycling (>=4 mood ep/y)?
Avoid antidepressants/stimulants in rapid cycling or Hx of antidepressant induced mania
Ev & treat underlying medical conditon, sub abuse
Optimise mood stabiliser treatment: valproate, Li, lamotrigine
What are the non-pharm reco for bipolar disorder?
Psychoeducation: chart mood changes, strategies for coping w stressful life events, importance of compliance w thera
Psychothera (e.g. indi, grp, fam)
- CBT
Stress reduction thera, relaxation thera
Sleep hygiene
Nutrition
Exercise
- Reg aerobic & wt trg at least 3x a week
