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3153 psych > bipolar > Flashcards

bipolar Flashcards

1
Q

bipolar disorder definition

A

Severe mood swings
Lifelong, cyclical mood disorder with variable course
* Recurrent fluctuations in mood, energy, behaviour
* Duration dominated by depressive episodes

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2
Q

bipolar sx presentation WHEN?

A
  • 1st ep in teens
  • first major dep (F), mania (M) peaks 15-19 yo
    * lasts from wks - mnths if untx
  • rapid cycling (freq epi of mania –> dep) as illness progress
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3
Q

rapid cycling

A

=/> 4 ep in 12mnths

  • mania, hypomania, or depressive episodes
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4
Q

causes of bipolar

A

1) genetics (relatives with mood d/o) (chromosone 18, 11p15, 21)

2) induced by tx
3) induced by general medical conditions
4) hx of trauma
5) physical stressors
6) seasonal changes

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5
Q

induced by tx

A
  • Antidep
    • Induce manic in few days ~ 2wks
    • Incr NE, DA transmissions
    • MANIC SWITCH
  • ECT
    • Depressed –> hypomanic/ manic mood
    • Use in refractory MDD
    • Voltage stimulate electro-activity, large/ fast release of neurotransmitters
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6
Q

secondary causes of mania

A
  • CNS disorders (tumor, stroke, head injury, subdural hematoma, multiple sclerosis, SLE, temporal lobe seizure, Huntington’s)
  • CNS infections
    • Encephalitis, neurosyphilis, sepsis, HIV
  • Electrolyte or metabolic abnormalities
    • Ca, Na fluctuation,
    • Hyper/hypo BGL
  • Endocrine or hormonal dysregulation
    • Addison, Cushing’s
    • hypothyroidism (dep)
    • Hyperthyroidism (mania)
    • Menstrual related/ preg related/ perimenopausal mood
  • Vitamins, nutritional deficiencies
    • Essential aa, FA, vit B
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7
Q

2nd causes (medications/ drugs) that induce

A
  • Drugs of abuse:
    • alcohol intoxication, hallucinogens, marijuana (psychosis, paranoia, ANX, restlessness)
  • Drug withdrawal state
    • Alcohol, a2 agonist, antidep, barbiturates, benzodiazepines, opioids
  • Antidep
    • MAOi, TCA, 5HT/ NE/ DA reuptake inhibitors
    • 5HT antagonists
  • DA-augmenting agents
    • CNS stimulants, amphetamines, cocaine, sympathomimetics, DA agonist/releasers/ reuptake inhibitors)
  • NE augmenting agents
    • A2 antagonists, b-agonists, NE reuptake inhibitors
  • Steroids — confusion
    • Anabolic, CS, adrenocorticotropic
  • Thyroid preps
    • T3 > T4 (potency)
  • Xanthines
    • Caffeine, theophyllines (asthma)
  • OTC weight loss agents, decongestants
    • pseudoephedrine
  • Herbal pdts (st John’s wort)
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8
Q

low mood sx

DIGES. CAPS

A
  1. depressed mood
  2. interest diminished, anhedonia
  3. guilt, low self esteem
  4. energy
  5. sleep incr/ decr
  6. conc poor
  7. appetite incr/ decr
  8. psychomotor agitation/ retardation
  9. suicide ideation
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9
Q

high moods
DIGFAST

A
  1. distractibility (fraustrated)
  2. irresponsible behaviour
  3. grandiosity
  4. flight of ideas (racing thoughts)
  5. activity incr
  6. sleep decr
  7. talkativeness
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10
Q

DSM-5 dx of bipolar

A

—> Based on duration, n.o. of sx, degree of functional impairment

  • Major depressive: sx > 2wks (functional impairment) dep/ loss interest + 3 other sx
  • Manic: sx =/> 1wk (functional impairment) Elevated mood + 3 sx // 4 sx (if mood irritable)
  • Hypomanic: sx =/> 4 d (no functional impairment, no psychosis)
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11
Q

mood disorders

A
  • Depressive disorders
    ○ MDD = unipolar + somatic & cognitive sx
    ○ Dysthymic disorder = depressed mood (not MDD), > 2yrs
  • Bipolar disorder
    ○ Bipolar I = mania +/- depressive ep
    ○ may have anxious or atypical features
    ○ Bipolar II = hypomania + depressive ep

bipolar II –> I eventually

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12
Q

tx general assessments similar to other psych but

A
  • preg test (SV, Li, CBP)
  • toxicology (sub-induced/ withdrawal sx)
  • med conditions (delirium, Psychosis, Depression, ANX, Insomnia, Thyroid dysfunction, DM)
  • MSE (high risk of suicidality - impulse)
  • pgx: if start CBP, HLAB*1502
  • PGx: CYP2D6 poor metaboliser (risperidone, aripiprazole)
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13
Q

psych rating scales
- usually used in research

A
  • mood (YMRS, young mania rating scale)
  • general/ functioning (CGI, clinical global impression)
  • health-related QOL assessment (psychological general well being)
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14
Q

tx goals

A
  1. Reduce freq, severity, duration of mood episodes
  2. Prevent suicide
  3. Maximise adherence with therapy
  4. Minimise ADR (employ meds with most acceptable tolerability, fewest drug interactions)
  5. Acute tx phase = Eliminate mood ep with remission of sx
  6. Maintenance/ continuation tx phase
    - reduce mood ep
    - reduce suicide ideation/ attempts
    - regain psychosocial functioning)
    - Avoid stressors or substances that may ppt an acute mood ep
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15
Q

non pharm

A
  • Psychoeducation (disorder, tx, monitoring for pt and caregiver)
    ○ Recognise early s&sx of mania and depression
    ○ Chart mood changes
    ○ Importance of compliance with therapy
    ○ Psychosocial, physical stressors and sub that ppt mania ep
  • Psychotherpy
    ○ Indiv, grp, family
    ○ Interpersonal cognitive behavioural therapy (CBT)
  • Stress reduction techniques, relaxation therapy
  • Sleep hygiene
    ○ Regular sleep, wake schedule
    ○ Avoid alcohol, caffeine intake ON
  • Nutrition
    ○ Protein rich foods, drinks, essential FA, supplemental vit and minerals
  • Exercise (aerobic, weight TDS)
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16
Q

pharm tx course

A
  • Short course of benzodiazepines (adjunct)
    ○ Help pt relax and sleep
    ○ Onset in hrs
    ○ Taper off when condition improved, mood stabilier optimised
  • Start mood stabilisers (mania or dep)
    ○ onset for stabilising mood: 3-5d
    ○ Counsel pts: mood stabilising, cause drowsiness (ON)
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17
Q

mood stabiliser select by

A

○ Response (change in sx)
○ Tolerability of SE
○ Serum drug lvl when applicable
○ Avoid drug interactions
○ Type and trend of mood ep
○ Suicide risk: Li best to reduce suicide
○ Onset to stabilise mood in 3-5d, but hrs to relieve agitation

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18
Q

maniac control

qora

A
  • APS
    * SGA: olan, quet, (titrate) risp (severe mania), aripip (LAI), haloperidol
  • Li (TDM)
  • SV (least preferrred, X child bearing)

(combi from any 2 grp: except SV + LAMO)

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19
Q

bipolar depression control

A
  • Li
    * 1st line for maintenace, suicide prevention
  • APS (quet, cariprazine)
    * + SSRI: fluoxetin (olan)
    * FGA: lurasidone
  • Lamotrigine
    * not anti-maniac, only antidep
    * +/- APS (mania)
    * just no VA (SJS, TEN)
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20
Q

Li - mixed features
MOA

A
  • Normalise/ inhibit 2nd messenger system
    • Reduce PKC
      • Alter cation transport across cell mem in nerve and muscle cells
      • reduce reuptake of serotonin and/or norepinephrine
      • inhibit second messenger systems
  • Decr 5HT uptake
  • Decr DA release
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21
Q

Li dose

A

400-800mg/day

Max 1.8g/d

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22
Q

Li TDM

A

Narrow TI: TDM
therapeutic range: (0.6 - 1 mmol/L) – lower in elderly
Target: SS (12hrs after dose)

Acute mania = 0.8-1 mEq/L
Maintain = 0.6-1 mEq/L

5-7d (after initiate) –> q3mnths (1st yr) –> q3-6mnthly thereafter (stable)

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23
Q

SE of Li common at

A
  • > 0.8mEq/L
  • Acute tremors, polyuria
  • hypoTHY, ECG change
  • Weight gain, N, fatigue, cognitive impair, DM
  • Li toxicity
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24
Q

Li toxicity

A

1.5- 2 (mild): NVD, lethargy, confusion, hand tremors, drowsy

2-2.5 (mod): severe NVD, slurred speech, confusion, ataxia (coord), blurred vision, lethargy, tinnitus, apathy

> 3 (severe): severe NVD, imparired consciousness, deep tendon reflexes, stupor, coma, seizure, death

25
Q

DDI with Li

A
  • Li toxicity (incr Li lvl) : STAND
  • Neurotoxicity: CBP, dilitiazem, losartan, methyldopa, metronidazole, phenytoin, verapamil
  • (decr Li conc) Enhance renal elimination: caffeine, theophylline
26
Q

STAND

A
  • Low Na
    ○ (body try to accumulate Na back into blood, Na, Li similar monocation + small size)
  • Thiazide (incr Li reab)
  • ACEi, ARB (decr GFR, Li reab)
  • NSAID (reab Li PGE2)
  • dehydrate (Na,Li reab)
27
Q

monitor for Li

A

TFT, electrolytes (Ca, Na)
RENAL
metabolic (BGL, lipid, BMI)
FBC
ECG

(baseline + 6-12mnthly)
* physical exam (preg) at base only

28
Q

SV – mixed (more mania ) MOA

A
  • Incr GABA
  • Decr DA turnover
  • May decr PKC
  • Normalise Na, Ca channel inhibitors
  • Antikindling properties
    * Prevent sx from getting more severe
29
Q

dose of SV

A

Initial: 400-750mg/day

LD 20mg/kg/day (max 60mg/kg/day)
Max 2.5g . Use divided doses

food delays absorption

30
Q

SE of SV

A
  • Hepatotoxic
  • rash, SJS/TEN
  • High dose: GI, pancreatitis, N, dizzy, somnolence, hyperNH3, ataxia, tremor, incr weight
31
Q

DDI of SV

A

Risk of SJS w/ LAMO (incr conc)

acts as a CYP Inhibitor (2C9, 2D6, 3A4/3) not 450

32
Q

monitor SV

A

baseline + 6-12mn: FBC (thrombocytopenia), LFT, metabolic (BGL, lipid, bmi), TDM

base: physical exam (rash, reg, alopecia, SJS/TEN)

33
Q

SV TDM

A

therapeutic range: 50-125 mg/L
trough sample, before 1st dose of day
NOT ROUTINE (unless poor adherence/ effectivness/ toxicity)
* 2-3d after initiation/ change dose

34
Q

CBP - mixed (more mania) MOA

A
  • Incr glutamate transport
  • Block voltage Na+ channels
35
Q

CBP dose

A

2nd line after Li, SV

Initial: 200-1800mg/day (2-4 divided dose)
* due to autoinduction to active metabolite, start at lower dose

Max 1.6g

36
Q

CBP SE

A
  • GI, CNS toxicity
  • Decr Na, WNC, blood dyscrasis
  • Rash, SJS/TEN
37
Q

CBP DDI

A

Induce CYP1A2, 2C9/10, 3A3/4

autoinduction – 3A4, 2C9 (incr active metabolite)
Agranulocytosis w/ clozapine

38
Q

CBP monitor

A

pgx: HLA-B*1502 allele genotype (sjs/ ten)

  • BASE + 6-12mn: FB (thrombocytopenia), renal (Na), LFT, TDM
  • base: physical exam (preg, rash, SJS/TEN, gx)/ metabolic (BGL, lipid, BMI)
39
Q

CBP TDM

A
  • > 7mg/L bipolar (epilepsy at 4-12)
  • TROUGH (morning before st dose of day)
  • monitor: initiate (2-4 wk reach ss) –> q6M (1st yr) –> annuals
40
Q

lamotrigine – dep only
MOA

A

Block voltage activated Ca2+ and Na+ channels

41
Q

LMT dose

A

Initial: 25mg/day
Adjust 2wkly

50-200mg day in divided dose

42
Q

LMT SE & DDI

A

Rash (esp with VA which incr LMT dose)
Less sedation & weight gain than others

43
Q

monitor LMT

A

base + 6-12mn: LFT
base: physical, FBC, preg, renal

44
Q

BZP as adjunct

MOA and dose

A
  • potentiates GABA
  • short term
    (short) Lorazepam 0.5mg TDS, max 10mg/day
    (long) Clonazepam 0.25mg BD, max 4mg/day

since onset 3-5d for mood stabilising effect to

45
Q

BZP SE

A

CNS depression
Sedation
Cognitive, motor impair

Dependence, withdrawal

46
Q

manage poor resp

A
  • switch/ augment
  • ECT
  • antidep
  • bipolar d/o with rapid cycling
47
Q

switch/ augement by

A
  • If non-responsive/ intolerant to ADR of 1st line drugs should be switched
  • Mania not responded in 2-4wks with 1st line
    ○ Augment with another 1st line
    ○ Switch to SGA (olanzapine)
    ○ Reserve CBP if fail above
48
Q

ECT

A
  • Severe/ tx resistant manic/ depressive sx, preg
    ○ Can worsen mania
    ○ Alt days 9-12sessions
  • Omit Li, anticonvulsants ASM, BZP =/> 12hrs before
    ○ Except when lorazepam/ clonazepam used for catatonia
49
Q

add antidep

A
  • Recurrent depressive ep require LT Li, quetiapine, olan+fluoxetine, lamo, lurasidone, cariprazine
  • Counsel on risk of SUICIDE
50
Q

rapid cycling manage

A
  • Avoid antidep/ stimulants in rapid cycling or if hx antidep-induced mania
  • Antidep-induced rapid cycling
    ○ Avoid or taper off antidep and other agents that incr NE/ DA activity
    ○ CNS stimulants, sympathomimetics, caffeine
  • Tx hypoTHY, hormonal imbalance, sub abuse
  • Optimise mood stabiliser: SV, Li, LAMO
51
Q

preg

A
  • should be planned, weigh risk-benefit
    * taper off meds before med
    * avoid meds 1st trimester
    * throughout preg (teratogenic risk in 1st trimester)
  • AVOID
    SV (neural tube defect, spina bifida)
    Li (fetal thyroid goiter)
    CBP (teratogenic)

– safer: FGA > SGA (quet, olan, ris – gestational DM)
– ECT (severe mania)
– LAMO

52
Q

breastfeeding

A
  • risks-benefits
  • all are secreted in breast milk
  • maybe (olan, quet / cloz but not BF)
53
Q

CVS

A

consider VA
monitor: BP, HR, peripheral oedema

APS: QTc prolong
Li: cardiac arrhythmia

54
Q

liver impairment

A

Li

55
Q

renal impairment

A

not Li
consider SV (monitor serum lvl)

56
Q

child/ adol

A

consider Li, SV

(SV not preferred in women with childbearing potential)

57
Q

elderly

A

all psychotropics incr risk of SE
* avoid renal excreted Li
* avoid CBP (DDI, SE)

LAMO not sig influenced by age (still need mania control + APS)

58
Q

suicidal behaviour

A

Li first line (optimise dose, level TDM)

59
Q

aggressive behaviour

A

BZP (short term)/ add on APS

optimise dose, lvl of existing (Li, SV)

3153 psych (11 decks)

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