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Flashcards in Bipolar Deck (32):
1

Side effects of Lithium

Common:
GI: Metalic taste, Wt gain, N and V and D
CNS: Fatigue, vertigo and headache,
Haem: Leukocytosis
Endocrine: Hypothyroidism - common esp F, HyperPTH

Nephrogenic DI: Polydipsia and polyuria - reduced response to ADH
oedema
Fine tremor
Muscular weakness and extrapyramidal feature
Cognitive - memory loss
? T wave flattening and inversion
Leukocytosis
Teratogenicity: Ebstein abnormally CVS.

2

Side effects of Atypical antipsychotics

Extra pyramidal symptoms and metabolic disturbances
or QT prolongation, Cardia problems and rarely neuroleptic malignant syndrome.

3

Interactions of Risperidone

Carbamazepine

4

What monitoring is required for Lithium

Monitor twice weekly until stable for 4 weeks.
12 hour after last dose after 5-7 days of stable dosing.
Repeat every dosage adjustment or 3-6 months.
Aim for 0.6-0.8mmol/L.
Before starting Kidney function test as Lithium is renal excretion.
Electrolyte as lithium affect Na and water regulation and can Inhibit ADH. (Monitor every 3-6 months)
TFT - can cause Hypothyroidism. (6-12 months).
Parathyroid Hormone and Wt 12m.

5

Different types of Bipolar

Bipolar 1 = Mania but can't function
Bipolar 2 = Hypo mania but can still function

6

DSM V criteria of manic Episode

A) A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goal-directed activity or energy, lasting at least 1 week and present most of the day, nearly every day.
B) During the period of mood disturbance and increased energy or activity, 3 (or more) of the following symptoms (4 if the mood is only irritable) are present, significant degree and represent a noticeable change from usual behavior:
G - Grandiosity
S - sleep decrease need
T - Talkative
P - pleasurable activités with painful consequence
A - Goal directed activity
I - Flight of idea
D- Distractability
C) The mood disturbance is sufficiently severe to cause marked impairment in social or occupational functioning or to necessitate hospitalisation to prevent harm to self or others or there are psychotic features.
D) The episode is not attributable to the physiological effects of a substance or medication
Note: Criteria A-D constitue a manic episode. At least one lifetime manic episode = Bipolar 1

7

DSM V criteria for a hypomanic Episode

A) A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goal-directed activity or energy, lasting at least 1 week and present most of the day, nearly every day.
B) During the period of mood disturbance and increased energy or activity, 3 (or more) of the following symptoms (4 if the mood is only irritable) are present, significant degree and represent a noticeable change from usual behavior:
G - Grandiosity
S - sleep decrease need
T - Talkative
P - pleasurable activités with painful consequence
A - Goal directed activity
I - Flight of idea
D- Distractability
C) The Episode is associated with an unequivocal change in functioning that is uncharacteristic of the individual when not symptomatic.
D) The disturbance in mood and the change in functioning are observable by others.
E) The mood disturbance is NOT SEVERE ENOUGH to cause marked impairment in social or occupational functioning or to necessitate hospitalisation. If there are psychotic features, the episode is, by definition, Manic
F) The episode is not attributable to the physiological effects of a substance
Note: Criteria A-F constitute a hypomanic episode. Hypomanic episodes are common in bipolar 1 disorder but are not required for the diagnosis of bipolar 1 disorder.


8

Male vs female for bipolar

Equal prevalance

9

Examination finding for Bipolar

G I - excited, talkative, sometimes amusing and frequently hyperactive. +/- grossly psychotic and disorganised and require physical restraints and IM sedation
Appearance
Attitude
Behaviours
Mood and affect - euphoric, irritable, low frustration tolerance (leads to anger and hostility), may be emotional labile by switching from laughter to irritability to depression in minutes to hours.
Speech - can’t be interrupted while speaking, intrusive nuisances. often disturbed. louder, more rapid and difficult to interrupt the more manic they get. Filled with jokes, puns, rhymes endplays on words and irrelevancies. Worsen as concentration fades and flight of ideas and clanging and neologism appear
Thought process - easily distracted, unrestrained and accelerated flow of ideas.
Thought content - Self-confidence and self aggrandisement
Perceptions - Delusion in 75%. Include: great wealth, extraordinary abilities or power.
Cognition
Alertness
orientation - intact
Attention - easily distractible
Memory - intact
visuospatial functioning
Language functions
Executive functions -
Impulse control?- 75% assertive or threatening. Attempt suicide and homicide
Insight - little insight into disorder.
Judgement - Impaired (hallmark feature). Break laws, sexual, finances,

10

Treatment for Acute mania

Medical emergency - admit, R and R then ITO
Mood stabilisers agents - Lithium or/and
Antipsychotic - Risperidone, olanazepine, Quetiapine
Sedative for the short term - diazepam or lorazepam

11

Treatment for bipolar depression

Antidepressant in combination with prophylaxis drug as antidepressants cause hypomania or Mania.
Anticonvulsant Lamotrigine shows antidepressant effects in bipolar.
Quetiapine

12

Maintenance treatment of bipolar

Educate patient and family about condition
Statistics - 50% relapse in first 5 months off lithium
90% of patients who have a manic episode with have another episode in their life. average is 4 in 10 yrs. 5-10% have 4 episodes in a year (rapid cycling)
Risk assessment - 10-15% of bipolar patient completed suicide.
Inpatient vs out patient
MDT - Specialist psychiatric care, GP, psy
CBT, Assertive community treatment, social skills programs. Shown to improve compliance
Manage comorbidity - monitor for substance use, anxiety and panic disorders.
Maintain physical health - quit smoking, CVS risk factors.
Work and family life
Medication - lithium, carbamazepine and valproate
Continue Medications for adequate duration - 1st episode continue for 1 yr, if multiple episode an long term is needed.
First line Lithium carbonate 125-500mg orally twice a day for 2 weeks and then dose adjust.
AE - Sedation, cognitive impairment, tremor, wt gain, rash
If using valproate or carbamazepine then liver and haematological functioning prior to and just after starting.
ECT - May cause a manic episode in bipolar patients but has been shown to be anti manic intervention with 80% experiencing marked improvement.

13

MOA of lithium

modulate the NT induced activation of second messenger systems

14

Indications for lithium

Acute mania, prophylaxis of bipolar, treatment resistance depression, adjunct to antipsychotic in schizophrenia etc.

15

Interactions of lithium

Concentrations are increased on ACEi's, NSAID, Diuretic
Concentrations are decreased on Antacids, theophylline

16

Counsel a patient on starting lithium

Prior to starting assess - Kidneys, thyroid, and parathyroid, FBC, U&E, eGFR, TFT, Parathyroid function, Pregnancy test, ECG
Advice them of Adverse effects
Need fro routine clinical and serum monitoring.
Symptoms that indicate need for dose adjustment = confusion, unsteadiness, nausea, Diarrhoea or worsening tremor.
Monitoring
8-12hr after last dose
Weekly after starting until stable for 4 weeks.
Then 3 monthly lithium levels and renal function (U&E, eGFR) 3-6 monthly and TFT 6-12 monthly in addition to clinical assessment.
Annual Hyperparathroidism, calcium concentrations.
Stay hydrated
Don't not stop taking the tablets suddenly as it leads to Mania. Need to withdraw slowly over 2months or more.

17

Precaution of Lithium

renal excreted - adjust dose in kidney disease
Lithium toxicity is common - pt and family need to be educated to recognise.
Drugs that increase lithium levels: Thiazides, NSAIDS and ACEi. Antipsychotic work synergistically to increase neurotoxicity.
Pregnancy, breast feeding
Thyroid disease
cardiac conditions
Neurological conditions eg parkinson’s or Huntington’s

18

Signs of toxicity in Lithium

Develop above 1.5mmol/L
Nausea and vomiting, apathy, coarse tremor, ataxia, neurological signs (hemiplegia) disorientation, dysarthria, muscle twitches, Impaired consciousness, acute kidney failure and death.
Prolonged toxic level = irreversible brain damage.
ECG: T wave change
Tx - supportive = adequate hydration, renal function and electrolyte balance. Anticonvulsants may necessary for convulsions and haemodialysis may be indicated in cases of renal failure.

19

MOA of Sodium valproate

Inhibits GABA transaminase.

20

Indications for sodium valproate

Epilepsy
Acute mania
Prophylaxis of bipolar

21

AE of Sodium Valproate

Increase appetite and wt gain
sedation and dizziness
Ankle swelling
Hair loss!
N and V
Tremor
Haematological abnormalities - Prolongation of bleeding time, thrombocytopenia, leucopenia
Raised Liver enzymes - very uncommon

22

What is cyclothymic disorder

Mild chronic mood disorder with numerous depressive and hypo manic episodes over the course of at least 2 years

23

What is bipolar disorder due to another medical condition

Need evidence the mood disorder is a direct consequence of a general medical condition eg frontal lobe tumour

24

What is substance/medication induced bipolar disorder

Due to substance intoxication, withdrawal, or medication eg amphetamine

25

Criteria for Cyclothymic disorder

A - 2yr of numerous hypo manic symptoms that don't meet the criteria and numerous depressive symptoms that don't meet the criteria
B - symptoms free period less than 2 months
C - not major depressive, mania, or hypomania
D - not schizophreniform disorder, schizophrenia, schizophreniform disorder, delusion disorder or other
E - Not substance or medical condition
F - impairment in functioning.

26

Things to exclude before Dx cyclothymic

Seizure
Substance - cocaine, amphetamine and steroid
PD - borderline, narcissistic, histrionic, antisocial PD
ADHD
Bipolar 2

27

Indications for ECT

Major depression refractory to tx
Psychotic depression refractory to tx or acute
Catatonic stupor
Severe suicidality
Food refusal leading to nutritional compromise
Pregnancy or other conditions that need rapid anti depressive effect
Schizophrenia - short term relief only in acute not chronic
Mania
Atypical psychosis
Neuroleptic malignant syndrome.

28

Adverse effects of ECT

major one is memory loss
CVS - increase or decrease HR, BP, atrial arrhythmia, ectopic, AV block or asystoli
CNS - Increase cerebral blood flow, increase ICP, disorientation, delirium.

29

Pre procedure stuff for ECT

Hx - problems with aneasthia, Risk factors: Cardiac schema and arrhythmia, HF, tumours, neural issues, skull fractures.
Ix - Serum electrolyte, if affected by other med e.g. diuretics. ECG if over 50yr

30

Post procedure stuff for ECT

Short acting beta blocker IV if increase HR and BP
IV nitroglycerine, Nicardipine and clonidine.

31

When describing bipolar patient what do you need to mention

Type of episode - manic, hypomania, depressive or mixed
Severity - mild, moderate, severe and whether psychosis
Remission status - partial or full
Recent course - rapid cycling or not.

32

Contraindications of ECT

Increased ICP