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Flashcards in Bipolar Deck (20):
1

bipolar disorder

episodes of major depression interspersed w. periods of mania or hypomania

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Manic episode

period of abnormally elevated or irritable mood lasting at least 1 week: inflated self esteem, dec need for sleep, talkative, racing thoughts, distractability, dec judgement, hard to treat

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Hypomania

less exaggerated form of mania

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Pathophysiology of bipolar disorder

changes in the limbic system, basal ganglia, and hypothalamus leads to dysregulation of neurotransmitter systems, fluctuations in norepi/DA, fluct in intracerebral ca level, endocrine dysfunction, fam hx, environment

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Bipolar 1

mood disorder w/ 1 manic/hypomanic and 1 depressive episode, episodes are followed by sx free periods

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Bipolar 2

major, recurrent depressive episodes w/ hypomania, suicidal thoughts, usually does not require hospitalization

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Clinical course of bipolar

1st episode usually Manic, untreated episodes can last for months, most have multiple episodes

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Goal of Tx

control sx, reduce frequency of cycling, cure is not realistic, likely lifelong therapy, use BZD and antipsychotics for acute episodes

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TX options

mood stabilizers- lithium, anticonvulsants- valproate, carbamazepine, lamotrigine, oxcarbazepine, AAPs, consider acute vs maintenance, current mood state, longitudinal hx of pt, comorbidities, side effects

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Lithium

gold standard, effective in classic mania w/ euphoria, 100% renally eliminated, long term maintence therapy but 30% do not respond, dec # and severity of episodes, lots Dis

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Lithium MOA

mono-valent cation, Li, effects anion exchanges and Na transport in nerves, normalizes synaptic transmission of NE, 5HT, DA, takes 5-14 d onset

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Lithium ADRs

tetatogenic cat X, early onset- polyuria, polydipsia, dry mouth, hand tremor, GI upset, HA, memory impairment, long term- polyuria, polydipsia, tremor, hypothyroidism, acne, EKG changes, inc WBC

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Toxicity w/ Lithium

Mild- more severe hand tremor, GI, confusion, ataxia, slurred speech, mod-severe- muscle tremor, coma, seizure, hyperreflexia, CV colapse, death

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Lithium advantages

will control manic pt w/out feeling drugged, will normalize mood, very good prevention to dec mood swings, less severe relapse, blood conc monitoring, cheap

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Lithium disadvantages

narrow therapeutic range, pt compliance, toxicity knowledge, delayed onset, rapid cyclers are poor responders, expense of blood tests

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Depakote

3-5 d onset, more effective for rapid cyclers, mixed episodes, dose may be limited by GI, also sedation, minor elevations in LFTs, wt gain, hyperammonemia, hyperandrogenism syndrome in young females

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Carbamazepine (Tegretol)

more effective for rapid cyclers, mixed episodes, 1-2 w onset, many DI, induces its own metabolism, good add on or 2nd line, sedation, N/V rash hypotension

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Lamotrigine (Lamictal)

indicated for maintenance tx of BP 1 disorder, effective in depressive spectrum of bipolar disorders, not for a manic state, more effective as add-on

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Other tx options

oxcarbazepine (but hypoNa), gabapentin, topiramate (good if migraines), AAP (all proven effective, use in addition to other agents

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Treatment guidelines

lithium, VPA, CBZ, AP, short term BZDs, maintenance- monotherapy if possible, lithium, VPA, lamotrigine, depressed phase- use anti-depressants cautiously, flip into mania