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bipolar Flashcards

1
Q

general bipolar

A
  • lifelong, cyclical mood disorder
  • recurrent fluctuations in mood, energy, behaviour -> severe mood swings
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2
Q

differences in 1st episode presentation by gender

A
  • males: manic episode
  • females: depressive episode
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3
Q

progression of bipolar disorder by age

A

10 - 20: mild bipolar mood swing
20: first major depression
20 - 30: first mania and post-mania depression
30: depression
30 - 40: rapid cycling between mania and depression

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4
Q

tldr risk factors for bipolar

A

1) genetics
2) treatment induced
3) medical conditions
4) history of trauma
5) physical stressors
6) seasonal change

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5
Q

genetic risk factors for bipolar

A
  • family history
  • loci on genes and X chromosomes: 18, 11p15, 21
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6
Q

treatment induced bipolar

A

1) ECT
2) drug abuse, intoxication
3) drug withdrawal state
4) antidepressant (increased NE or DA transmission)
5) DA-augmenting agents (CNS stimulants increase DA transmission)
6) NE-augmenting agents (alpha-2 antagonist, increase NE transmission)
7) steroids
8) thyroid preparations
9) herbal products
10) pseudoepinephrine

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7
Q

general medical conditions that cause bipolar

A

1) CNS disorders (Stroke, head injuries, multiple sclerosis)
2) CNS infections
3) electrolyte/metabolic imbalance
4) endocrine/hormonal dysregulation

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8
Q

history of trauma that cause bipolar

A

perinatal trauma, head trauma, physical abuse

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9
Q

pathophysiology of bipolar

A

excessive NE or DA neurotransmission -> manic episode

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10
Q

clinical presentation of bipolar

A

1) history of mania/hypomania not caused by other conditions or substances
2) high mood (manic) symptoms

  • abnormal and persistently elevated, expansive, irritable mood + 3 other symptoms in 1 wk period (DIGFAST)
    ** distractability and easily frustrated
    ** irresponsible and erratic uninhibited behaviour
    ** grandiosity
    ** flight of ideas
    ** activity increased, psychomotor agitation
    ** sleep need decreased
    ** talkativeness

3) depressive symptoms (In.SAD.CAGES)

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11
Q

description of bipolar mood episodes

A

1) major depressive episodes

  • symptoms > 2 wks with functional impairment

2) manic episodes

  • symptoms >/= 1 wk with functional impairment

3) hypomanic episodes

  • symptoms >/= 4 days, no functional impairment, no psychosis
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12
Q

DSM-5 classification for bipolar

A

1) bipolar I = mania +/- depressive episodes
2) bipolar II = hypomania + depressive episodes

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13
Q

how diagnosis for bipolar normally recorded

A

bipolar (Type) disorder with (Type of current/most recent episodes) (severity/psychotic/remission specifier)

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14
Q

general assessment of bipolar

A

similar to schizophrenia

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15
Q

non-pharmaco for bipolar

A

1) psychoeducation

  • recognise early signs and symptoms
  • chart mood changes
  • identify stressors that precipitate episodes
  • strategies for coping
  • development crisis intervention plan

2) psychotherapy

  • interpersonal therapy, CBT, behavioural couples therapy

3) stress reduction techniques
4) sleep hygiene
5) nutrition: protein rich, essential fatty acids, supplementation
6) exercise

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16
Q

initiation of bipolar therapy

A

1) short course PRN benzodiazepine

  • help patient relax and sleep
  • onset of effectiveness within hours
  • taper off when condition improved and mood stabiliser optimised

2) start mood stabilisers

  • acute and maintenance
17
Q

what to do when poor response to initial bipolar treatment?

A

1) Switch agent

  • if no response after 2 - 4 wks then switch to 2nd 1st line agent
  • if partial response after 2 - 4 wks then add on 2nd 1st line agent

2) ECT

  • for severe, treatment resistant

3) antidepressant

  • recurrent episodes need long term lithium and antidepressant

4) bipolar disorder and rapid cycling (>/=4 mood episodes per year)

  • X antidepressant/stimulant
  • treat underlying cause instead
18
Q

tldr type of mood stabilisers

A

1) mania

  • lithium
  • olan, quet, risp, ari, halo
  • valproate
  • combination of each

2) bipolar depression

  • lithium
  • quet, olan + fluoxetine
  • lamotrigine
  • combination
19
Q

lithium MOA

A

1) normalise/inhibit secondary messenger systems
2) maybe reduce PKC
3) reduce 5-HT reuptake and DA release

20
Q

lithium PK

A
  • not affected by liver, kidney clearance
21
Q

lithium lab values monitoring

A
  • TFT, electrolytes w Ca2+ and renal function, FBC, urinalysis, EKG, pregnancy test
  • taking samples
    ** 12 hrs after previous dose
    ** 5 - 7 days after initiation/titration cuz steady state after 5 days
22
Q

lithium SE

A
  • fine - coarse tremor, polyuria, hypothryoidism, cardiac effect (ECG change), N, weight gain, fatigue, cognitive impairment, diabetes insipidus
23
Q

lithium DDI

A

lithium toxicity

  • STAND
    1) sodium depletion: body reuptake more Na but reuptake Li instead cuz both Li and Na monovalent cation
    2) thiazide: promote water loss -> increase concentration in blood
    3) ACEi/ARB
    4) NSAIDs
    5) Dehydration
  • toxicity categories
    1) mild
    ** serum levels 1.5-2
    ** GI SE: N/V, loose stools
    ** CNS SE: lethargy, confusion, coarse hand tremors
    2) moderate
    ** serum level 2 - 2.5
    ** GI SE: severe N/V, diarrhoea
    ** CNS SE: slurred speech, worsening confusion, ataxia, blurred vision, profound lethargy, tinnitus, apathy
    3) severe
    ** serum level > 3
    ** GI SE: severe N/V, diarrhoea
    ** CNS SE: very impaired consciousness, increased deep tendon reflexes, stupor, coma, seizure, death
24
Q

valproate MOA

A
  • increase GABA levels
  • decrease DA turnover and PKC
  • normalise Na and Ca channels
  • antikindling properties
25
Q

valproate lab values monitoring

A
  • LT, pregnancy test
  • target: 50 - 125mcg/mL
26
Q

valproate SE

A
  • SJS/TEN
  • high dose: GI, thrombocytopenia, pancreatitis, weight gain
27
Q

lamotrigine

A
  • X TDM, increase dose by 2 wkly intervals
  • SJS/TEN w valproate
28
Q

carbamazepine bipolar

A
  • last line
  • increase glutamate transport
  • SJS/TEN (need HLA-B*1502 genotyping)
  • agranulocytosis w clozapine
29
Q

special populations for bipolar

A

1) Females of childbearing age: X valproate
2) pregnancy

  • X valproate & carbamazepine
  • Lithium increase risk of Ebsteins’ anomaly
  • antidepressant safer but monitor SE
  • consider ECT for severe cases

3) breastfeeding

  • all mood stabilisers enter breastmilk, weight risk benefit

4) cardiac disease

  • valproate
  • monitor for BP/HR increase & peripheral oedema

5) liver impairment: lithium
6) renal impairment: valproate, monitor serum levels
7) children: lithium, valproate
8) elderly: avoid antipsychotic and renally excreted drug
9) suicidal and aggression/violence: hospitalisation to optimise dose and levels of lithium

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