Wk 27 - Bipolar disorder

Question 1

What is bipolar disorder?

Answer 1

Occurence of 1 or more manic episodes, followed by episodes of major depressive disorder

Question 2

What is Bipolar I?

Answer 2

At least 1 manic or mixed episode

Question 3

What is Bipolar II?

Answer 3

At least 1 major depressive episode plus 1 milder manic syndrome (hypomanic episode)

Question 4

What is cyclothymic disorder?

Answer 4

Alteration in mood btw hypomania + mild depression

Question 5

What is bipolar characterised by?

Answer 5

• Elevated or irritable mood for > 1wk
• Impairment + at least 4:
• Distractibility
• Grandiosity
• Inc talking
• Reckless behaviour
• Racing thoughts
• Inc activity
• Dec need to sleep

Question 6

What are the key features of mania?

Answer 6

• Elevated
• Irritable mood
• Marked impairment in functioning

Question 7

What are the key features of hypomania?

Answer 7

• Elevated, expansive or irritable mood
• No psychotic symptoms
• Less impairment of functioning

Question 8

What are the key features of depression?

Answer 8

• Mild, mod or severe

- W/ or w/o psychotic symptoms

Question 9

What are the key features of rapid cycling?

Answer 9

4 episodes in a year

Question 10

When is the usual onset of bipolar disorder?

Answer 10

15 - 19 years

Question 11

Which race has a higher incidence of bipolar disorder?

Answer 11

Black + other minority ethnic groups

Question 12

What is the first choice for acute mania phase?

Answer 12

• Lithium
• Atypical antipsychotics
• Semisodium valproate

Question 13

What is the second line for acute mania phase?

Answer 13

• Benzodiazepines

- Carbamazepine

Question 14

What is the first choice for maintenance treatment of bipolar disorder?

Answer 14

• Lithium
• Carbamazepine
• Semisodium valproate
• Atypical antipsychotics

Question 15

When is an electrocardiogram offered to a patient?

Answer 15

• Physical examination identified a specific CVD risk
• Fam history of CV disease + sudden collapse
• CVD risk factors: cardiac arrhythmias
• Inpatient

Question 16

What should be monitored when on antipsychotics?

Answer 16

• Pulse + BP after dose change
• Weight + BMI weekly for 1st 6wks then 12 wks
• Blood glucose/Hba1c + blood lipid profile at 12 wks
• S/e
• Emergence of movement disorder
• Adherence

Question 17

Can you start combined antipsychotics?

Answer 17

No unless for ST

Question 18

When stopping, how many weeks is needed to reduce the dose?

Answer 18

4 wks to minimise risk of relapse

Question 19

What is lithium?

Answer 19

• Mimic role of Na in excitable tissue
• Penetrates voltage gated Na channel responsible for action potential generation
• Not pumped out by Na/K ATPase
• Interferes w/ phosphatidylinositol pathways + negatively affect hormone induced cAMP prod

Question 20

What are the pharmacokinetics of lithium?

Answer 20

• Oral admin
• Narrow therapeutic index
• Not prescribed unless monitoring available
• Sample taken 12 hrs after dose to achieve serum-lithium conc 0.4-1 mmol/L
• Peak serum 3-5hrs
• Several days to reach steady state

Question 21

What are the laboratory measurement of lithium?

Answer 21

• Serum levels checked after 5-7 days of initial prescription dose
• Once dose established, check every 4 wks then 3 months
• 5ml venous blood
• Timing of collection = vital for accurate interpretation of routine therapeutic monitoring
• Blood sampled 12 hrs after last dose

Question 22

What are the adverse effects of lithium?

Answer 22

• Dyspepsia
• ECG changes
• Polyuria + dipsia
• Oedema
• Tremor
• Muscle weakness
• Neutrophilia

Question 23

What are the counselling points of lithium?

Answer 23

• Maintain fluid intake + avoid dietary changes relating to sodium intake
• Minimal alcohol consumption
• Brand prescribe, monitor if changed
• Don’t take NSAIDs
• Hypothyroidism: lethargy, cold, weight gain = referral
• Fluid loss from di + vom = discontinue
• Monitor renal + thyroid on initiation + every 6 months

Question 24

What are the contraindications of lithium?

Answer 24

• Dehydration

- Untreated hypothyroidism

Question 25

What are the important points of lithium?

Answer 25

• Beneficial effects: 3- 4 wks
• Dehydration, red renal perfusion + infections predispose to Li+ toxicity
• Inc Li+ toxicity w/ diuretics, ACEIs + ARBs
• NSAIDs red Li+ excretion
• Inc risk of ventricular arrhythmias w/ amiodarone
• Check U&Es , LFTs + TFTs prior to initiation
• Measure serum Li+ conc. Every 3 months
• Monitor U&E s + TFTs every 6-12 months on stabilised regimens

Question 26

What are the important points of valproate?

Answer 26

• Starting: measure weight or BMI + full blood count + liver function tests (6 months + annually)
• Not be prescribed to women of child bearing age w/o pregnancy prevention programme
• Interactions w/ other anticonvulsants (carbamazepine + lamotrigine) olanzapine + smoking
• Don’t routinely measure plasma valproate levels unless evidence of ineffectiveness, poor adherence or toxicity
• Monitor sedation, tremor + gait disturbance in older people.
• Stopping: red dose over 4 wks to minimise relapse

Question 27

What are the important points of lamotrigine?

Answer 27

• Starting: full blood count, urea + electrolytes + liver function tests
• Interaction w/ valproate
• Contact doctor: rash when dose inc
• Inform if pregnant or planning
• Don’t routinely measure plasma lamotrigine levels unless evidence of ineffectiveness, poor adherence or toxicity
• Stopping: red dose gradually over 4 wks to minimise relapse