Bipolar disorder

Question 1

distractability, hyperactivity, sleep disturbance and irritability represent a change in baseline behavior

Answer 1

diagnosis of bipolar

Question 2

mania

Answer 2

euphoric or irritable mood, grandiosity, decreased need for sleep, pressured speech and racing thoughts and distractability and hyperactivity and impulsivity

Question 3

patient can present with major depressive episode and so it’s important to ask

Answer 3

response to prior antidepressants, if underlying bipolar may have reacted poorly or induced a manic episode

also screen for episodes of mania in life

Question 4

treatment of bipolar depression disorder

Answer 4

quetiapine- second generation anti psychotic

can use lurasidone and combo of olanzapine and fluoxetine.

can also be treated with lithium or lamotrigine or valproate

Question 5

why do we not want to give a SSRI to treat someone with bipolar depression?

Answer 5

can induce mania or rapid cycling >4 mood episodes per year.

Question 6

Drugs that increase lithium toxicity

Answer 6

diuretics, NSAIDS, SSRIs, ACEi or ARBs

Non dihydropyridine CCB (verapamil and diltiazem)

antiepileptic drugs (carbamazepine, phenytoin)

Question 7

Clinical presentation of lithium toxicity

Answer 7

neurological confusion, agitation, vertigo, ataxia, neuromuscular excitability (irregular coarse tremors, fasciculations, and myoclonic jerks)

Cardiac manfestations: bradycardia and prolonged QTc interval

Nephrogenic diabetes insipidus

Question 8

what are severe toxic lithium levels and what do you see?

Answer 8

lithium level of 2.5-3.5 mEq/L

NORMAL / goal levels: 0.8-1.2 mEq/L

see seizures and encephalopathy and coma

Note, drug levels may not correlate to degree of symptoms in acute toxicity

Question 9

what can easily cause lithium toxicity

Answer 9

anything that decreases renal excretion (volume depletion with diuretics, NSAIDs, ACEi)

Need to monitor lithium levels

Note, drug levels may not correlate to degree of symptoms in acute toxicity

Question 10

who is at risk for lithium toxicity

Answer 10

elderly pts due to reduced GFR

Question 11

treatment of lithium toxicity is:

Answer 11

supportive care with IV fluids,

benzodiazepines for seizures

gastric decontamination (bowel irrigation with polyethylene glycol)

if needed and HD for severe toxicity

Question 12

pt with bradycardia, prolonged QTc interval and on lithium for bipolar disorder. Started using NSAIDS for back pain and started on ACEi.

Answer 12

acute toxicity with lithium

see the cardiac manifestations.

Due to decreased renal perfusion increasing lithium levels.

Question 13

intolerable insomnia while on venlafaxine are suggestive of

Answer 13

treatment emergent mania

may have underlying bipolar disorder

always assess someone prior to starting a SSRI that they have a history of mania and hypomanic episodes

Question 14

prior to starting SSRI must ask about

Answer 14

periods of elevated mood, decreased need for sleep, racing thoughts, uncharacteristic risk taking behavior

ask family member as they may remember and pt may have limited insight, difficulty recalling, tendency to minimize the past manic or hypomanic episodes.

Question 15

sluggishness, confusion agitation and neuromuscular excitability with irregular course tremors

Answer 15

acute on chronic lithium poisoning

Question 16

acute intoxication of lithium

Answer 16

see nausea/ vomiting, diarrhea and late complication of neurological symptoms

Question 17

see thyroid disfunction and nephrogenic DI see this with

Answer 17

chronic lithium intoxication and this can happen over months to years

Question 18

management of lithium toxicity:

Answer 18

stabilize airway and circulation
saline infusion
HD is meant for levels >4 mEq/L or Levels >2.5 mEq/L + signs of any significant lithium toxicity (seizures, depressed mental status) or inability to excrete lithium

Question 19

hemodialysis for chronic lithium intoxication is meant

Answer 19

HD is meant for levels >4 mEq/L
Levels >2.5 mEq/L + signs of any significant lithium toxicity (seizures, depressed mental status) OR inability to excrete lithium