UW cases: Bipolar

Question 1

(1) ] A 19-year-old woman is brought to the emergency department by the police after she was found trespassing at an animal shelter. The patient had keys to a rental van, as well as numerous collars and leashes. She says, “The shelter is going to sell the animals to labs, where they’ll do horrible experiments on them. I’m the only one who can save them!” The patient quit her retail job a week ago to spend more time researching escape routes for the animals. Throughout the evaluation, she interrupts the physician to yell at other patients and hospital staff walking by the room. She repeatedly refers to herself as a “cat burglar” and then laughs loudly for a few minutes. Physical examination is unremarkable and urine drug screening is negative. Which of the following additional features is most likely in this patient?

Answer 1

Decreased need for sleep

A key feature of mania is decreased need for sleep due to increased energy.

Question 2

(2) 25 y/o woman + 3-week history of depressed mood, low energy, loss of motivation, and oversleeping following the break-up of a relationship. The patient is sleeping 12 hours each day and describes difficulty getting out of bed and showering and dressing in the morning. Her concentration is poor at work, and she has difficulty completing everyday tasks. The patient has no psychotic symptoms or suicidal ideation. She has a history of major depressive episodes at age 16 and 20. The patient was treated briefly with fluoxetine at age 20 but stopped the medication after a week as she did not like the way it made her feel. Following a rape at age 22, she was treated with trauma-focused psychotherapy for 6 months. The patient has no significant medical history. She drinks a beer several times a week and uses cannabis approximately once every other month. Physical examination is normal. After the physician discusses treatment options for depression, the patient chooses to have combination treatment with psychotherapy and medication. Which of the following would be most important to obtain prior to initiating pharmacologic treatment for this patient?

Answer 2

History of elevated mood

Question 3

(2) prior to initiating antidepressants for a major depressive episode, all patients should be screened for????? why?

Answer 3

all patients should be screened for a history of hypomania/mania to rule out bipolar disorder.

All antidepressants can induce mania, with the greatest risk occurring in patients with bipolar disorder.

Question 4

(2) Patients who have a major depressive episode and meet criteria for a past manic or hypomanic episode should be diagnosed with?

Answer 4

With bipolar disorder rather than unipolar major depressive disorder.

Antidepressant monotherapy should be avoided in these patients due to the risk of inducing hypomania/mania.

Question 5

(2) This patient’s history of early-onset depression, poor tolerability to a previous trial of antidepressant treatment, and a depressive episode characterized by lethargy and hypersomnia are especially characteristic of bipolar depression and should warrant careful assessment.

Answer 5

nu bbz ar cia differential tarp MDD ir bipolar depression

Question 6

(3) A 20-year-old woman is brought to the emergency department by police at 2:30 AM after she was caught attempting to scale a fence at the White House. The patient appears highly agitated and paces around the examination room. She has just flown in from out of state to “meet with the president about a foolproof plan for eliminating worldwide terrorism.” The patient has barely slept for the past week due to her intensive work on this plan. She speaks rapidly but periodically stops to shout, “I’m going to sue all of you for interfering with my right to meet with the president.” She refuses a cup of water offered by a nurse, flinging it across the room. The evaluation has to be stopped when the patient begins banging on the door and demanding to leave. Family history is significant for major depression in her mother. Temperature is 37 C (98.6 F), blood pressure is 148/84 mm Hg, pulse is 98/min, and respirations are 22/min. Urine drug screen is negative. Administration of which of the following medications is the most appropriate next step in management of this patient?

Answer 6

OLANZAPINE (vs valproate)

maniac episode

Question 7

(3) First-line treatments for mania include? 3

Answer 7

antipsychotics (eg, olanzapine), lithium,
and anticonvulsant mood stabilizers (eg, valproate).

Question 8

(3) Why in case was first line olanzapine?

Answer 8

Because this patient exhibits acute psychosis (eg, grandiose delusions) and escalating agitation (eg, shouting, banging on the door, throwing a cup of water), an antipsychotic such as olanzapine would be the next step in management because it can be administered intramuscularly and has a rapid onset of action. Both first- and second-generation antipsychotics are effective in managing mania and associated acute behavioral agitation.

Once this patient is calmer and willing to take oral medication, lithium or an anticonvulsant mood stabilizer could be given. Combination therapy with an antipsychotic plus lithium or valproate is often necessary to treat severe mania (eg, psychotic features, aggressive behavior, risk of harm to self or others).

Question 9

(3) olanzapine - i/m
vaproate and lithium - per os

Answer 9

.

Question 10

(3) acute mania table. Mx. Lithium - avoid in what?

Answer 10

in renal disease

Question 11

(3) acute mania table. Mx. Valproate - avoid in what?

Answer 11

in liver disease

Question 12

(3) acute mania table. Mx. antipsychotic - groups?

Answer 12

first and second generation

Question 13

(3) acute mania table. Mx.
Combination in severe mania?

Answer 13

eg. antiphychotic plius lithium or valproate

Question 14

(3) acute mania table. Mx. Adjunctive for insomnia, agitation?

Answer 14

benzodiazepines

Question 15

(4) A 35-year-old woman comes to the office due to poor energy. She says, “Although I have no energy, I still can’t sleep and am up most of the night. I drag myself to work but barely get anything done because I have no motivation and can hardly concentrate. I’m a horrible wife and mother. I don’t want to go out anymore or do anything. All I want to do is hide in my room and get into bed.” The patient has a history of 3 prior episodes of depression beginning at age 18. She was also hospitalized 3 years ago for aggressive behavior following an arrest for unauthorized use of her company’s funds to finance a personal business venture. At that time, she had excessive energy, slept 2 hours a night, and believed that she had a brilliant idea that would revolutionize the computer industry. The patient has no history of recreational substance use. There is a family history of depression in her mother, whose condition responded well to tricyclic antidepressants. Mental status examination is remarkable for psychomotor retardation, frequent tearfulness, depressed mood, and suicidal ideation. Which of the following is the most appropriate pharmacotherapy?

Answer 15

Quetiapine

Dx? Bipolar I

Question 16

(4) bipolar Tx scheme. MANIA. while episode, you give first line antipsychotic. what drug?

Answer 16

Haloperidol

Question 17

(4) bipolar Tx scheme. MANIA. during episode you give Haloperidol —> change to?

Answer 17

Lithium
Valproic
2nd generation antipsychotic

Question 18

(4) bipolar Tx scheme. MANIA. during episode you give any of: Lithium; Valproic; 2nd generation antipsychotic ——> whats next?

Answer 18

CONTINUE THESE DRUGS

Question 19

(4) bipolar Tx scheme. DEPRESSION. 4 drugs?

Answer 19

Lithium
Olanzapine-fluoxetine
Lamotrigine
2nd generation antipsychotic

Question 20

(4) bipolar Tx scheme. DEPRESSION. You give any of these: Lithium; Olanzapine-fluoxetine; Lamotrigine; 2nd generation antipsychotic. Whats next?

Answer 20

CONTINUE

Question 21

(4) bipolar Tx scheme.
2nd generation antipsychotics drugs?

Answer 21

Quetiapine, olanzapine,

lurasidone (only depression).

Question 22

(4) Bipolar disorder has different phases (acute mania, acute bipolar depression, maintenance).

Answer 22

.

Question 23

(4) Antidepressant monotherapy is avoided in patients with bipolar I disorder due to the risk for inducing mania. Antidepressants can sometimes be used with antipsychotics (eg, olanzapine plus fluoxetine) or mood stabilizers to decrease the risk for an antidepressant-induced switch from depression to mania.

Answer 23

.

Question 24

(4) Mood stabilizers (eg, lithium, lamotrigine).

Answer 24

Haloperidol is a first-generation antipsychotic that can be used in acute mania but not in acute bipolar depression

Question 25

(5) 30 y/o women + has Hx of 2 hospitalizations. 1 - for irritable mood. 2 - for depression and attempt to suicide. used venlafaxine, but does not use since discharge because she felt fine. NOW - lost 4,5 kg, does not go to work, depressed and tearful. Tx?

Answer 25

Lithium. Its bipolar. Common options for maintenance treatment of bipolar disorder include lithium and valproate. The second-generation antipsychotic quetiapine and the anticonvulsant lamotrigine have also demonstrated efficacy. Lithium would be particularly helpful in this patient because it would reduce the risk of suicide.

Question 26

(6) Bipolar + use psychiatric medication that is effective. Has fatigue, constipation, myalgias. Also use antihypertensive and statins. what drug cause symptoms?

Answer 26

Lithium Approximately 25% of patients treated with lithium will develop hypothyroidism. The HMG-CoA reductase inhibitor simvastatin can cause myalgias, but is not typically associated with constipation, fatigue, or bradycardia. Other side effects of statins include liver function test abnormalities and rhabdomyolysis.

Question 27

(6) Patients prescribed lithium should have be done what?

Answer 27

patients prescribed lithium should have baseline TSH levels drawn prior to starting therapy and TSH testing repeated every 6-12 months for the duration of treatment

Question 28

(6) hypothyroidism due to lithium. Tx?

Answer 28

Patients who develop hypothyroidism are generally managed symptomatically with addition of T4 (eg, levothyroxine) rather than discontinuation of lithium.

Question 29

(7) A 40-year-old man comes to the office due to low mood, decreased energy, and poor sleep for the past month. Although the patient spends up to 12 hours a day in bed, he gets only 4-5 hours of sleep and never feels rested. He is isolating himself from his family and says, "I eat only because I have to." The patient has previously had several similar periods of low mood but was never diagnosed or treated. He also has had periods lasting 5-6 days in which he gets a burst of energy, has "tons of new ideas in my head," and feels great. During these times, he works extra-long hours to complete additional projects at work, and he feels well rested despite sleeping 4 hours a night. Now the patient fears that his depression is having a major impact on his work and family life. He has been procrastinating on several projects and is frequently late to work. He has no motivation to spend time with his children or friends. The patient has increased his daily caffeine consumption to 6 cups of coffee and has an energy drink to counteract his fatigue, and he recently started using marijuana at bedtime to help him fall asleep. Mental status examination shows slow speech, a sad affect, and no suicidal ideation. Which of the following is the most likely diagnosis in this patient?

Answer 29

Bipolar II This patient's recurrent major depressive episodes and his history of hypomania (without marked impairment during the hypomanic episodes) are consistent with bipolar II disorder

Question 30

(7) Bipolar I vs II? how long lasts mania? (bipolar I)

Answer 30

In bipolar I disorder, mania lasts ≥7 consecutive days and includes severe symptoms that cause significantly impaired functioning (eg, inability to work, grossly disorganized behavior), require hospitalization, and/or include psychotic features. In addition, major depressive episodes can occur, but they are not necessary for the diagnosis of bipolar I disorder.

Question 31

(7) Bipolar I vs II? how long lasts hypomania? (bipolar II)

Answer 31

In bipolar II disorder, hypomania lasts ≥4 consecutive days and does not cause marked impairment in social or occupational functioning. In addition, patients must have had ≥1 lifetime major depressive episodes.

Question 32

(7) Although marked functional impairment is not seen during hypomanic episodes, patients with bipolar II disorder experience marked functional impairment during the major depressive episodes.

Answer 32

.

Question 33

(7) Major depressive disorder (MDD) is characterized by ≥2 weeks of major depressive symptoms. If there is a lifetime history of mania or hypomania, MDD is not diagnosed and a bipolar disorder is diagnosed preferentially.

Answer 33

.

Question 34

(8) bipolar I. Combination of medications is the most appropriate maintenance therapy for this patient?

Answer 34

Lithium or valproate combined with a second-generation antipsychotic (eg, quetiapine) is first-line combination therapy.

Question 35

(8) The combination of 2 second-generation antipsychotics is not first-line maintenance treatment for bipolar disorder. One antipsychotic in combination with lithium or valproate is preferred.

Answer 35

.

Question 36

(8) haloperidol - for acute mania. Not for maintenance.

Answer 36

.

Question 37

(9). 27 y/o. depressive episode with suicidal ideation, was hospitalized. got drug - good response. He has a history of migraine headaches, bipolar disorder, and tobacco use disorder. Examination is significant for a maculopapular rash over the patient's left scapula. most likely cause of this patient's condition?

Answer 37

Lamotrigine.

Question 38

(9). Lamotrigine adverses?

Answer 38

One of the most significant side effects of lamotrigine is a drug rash, a mild form of which occurs in up to 10% of those treated. The more severe mucocutaneous rashes of Stevens-Johnson syndrome (<10% body surface area skin detachment) and toxic epidermal necrolysis (>30% detachment) occur at a rate of 0.1% (10%-30% detachment is known as Stevens-Johnson syndrome/toxic epidermal necrolysis overlap).

Question 39

(9). Bipolar + Lamotrigine -> skin rash. Mx?

Answer 39

Lamotrigine should be discontinued at the first sign of rash and substituted with another agent. Most cases of lamotrigine-induced rash develop within the first 2 months of therapy.

Question 40

(10). Lithium toxicity. table. acute intoxication causes?

Answer 40

intentional overdose

Question 41

(10). Lithium toxicity. table. Chronic toxicity causes?

Answer 41

DECREASED RENAL PERFUSION (decr. lithium clearance): dehydration; drugs use = nsaids, ACEI, thiazide diuretics

Question 42

(10). Lithium toxicity. table. Acute toxicity CP?

Answer 42

GI: nausea, vomiting, diarrhea Late neurologic sequelae

Question 43

(10). Lithium toxicity. table. Chronic toxicity CP?

Answer 43

NEUROLOGIC!! lethargy, confusion, agitation, ataxia, tremor/pasficuclations, seizures

Question 44

(10). Lithium toxicity. table. Tx? 2

Answer 44

intravenous hydration Hemodialysis (severe cases).

Question 45

(10) in case, used drugs: lithium, risperidone, sertaline. Got cephalosporin for infection. Also ibuprofen and acetaminohen for temp. Became tremulous, uncoordinated, fasciculations, bilateral tremors. Drugs that caused it?

Answer 45

Lithium

Question 46

(11) Uses mood stabilizers and antipsychotics. + got thiazides. Now has ataxia, a generalized seizure that lasts 2-3 minutes. Cause?

Answer 46

Lithium toxicity

Question 47

(12). Wanted to break into city hall -> hospitalized -> got medications. Now has calcium of 13.4 mg/dL. Cause?

Answer 47

This patient's serum calcium level suggests that she was prescribed lithium, which can cause hyperparathyroidism and associated hypercalcemia.

Question 48

(12) lithium adverse?

Answer 48

hyperparathyroidism -> associated hypercalcemia nephrogenic diabetes insipidus, chronic kidney disease, and thyroid dysfunction (hypothyroidism)

Question 49

(12) lithium theratogenic effect?

Answer 49

first-trimester lithium exposure is associated with teratogenic effects (eg, Ebstein anomaly).

Question 50

(12) Current guidelines recommend a baseline basic metabolic panel (including blood urea nitrogen and creatinine), calcium, urinalysis, pregnancy test in women of childbearing age, and thyroid function tests before lithium is prescribed.

Answer 50

.

Question 51

(12) contraindications for lithium use? 3

Answer 51

CKD Heart disease Hyponatremia or diuretic use

Question 52

(13) A 22-year-old man comes to the emergency department with his roommate due to depression and thoughts of killing himself. The patient says, "I've been struggling for weeks, but my roommate convinced me to finally get help." The patient has not attended classes the past 2 weeks because he feels exhausted and has been sleeping throughout the day. He has no appetite and must force himself to eat at least 1 meal a day. The roommate says, "The whole week before he got depressed, he was doing great. He was reading ahead for class and working in the lab with almost no sleep. He was so excited about his research and would talk about it nonstop to anyone who would listen." The patient takes no medication. Physical examination and laboratory studies are unremarkable; urine drug screen is negative. He appears tearful and has suicidal ideation. The patient is admitted for inpatient psychiatric treatment. Which of the following is the most appropriate pharmacotherapy at present?

Answer 52

Quetiapine First-line medications for treatment of acute bipolar depression include the second-generation antipsychotics quetiapine and lurasidone.