Bipolar - Block 3

Question 1

What is depressive episode criteria?

Answer 1

1. Period of depressed mood or loss of interest/pleasure
2. Irritable (child/adolescent)
3. Last at least 2 weeks
4. Affects previoud functioning

Question 2

Manic eisode criteria?

Answer 2

A distinct period of abnormally and persistently elevated, expansive, or irritable mood for 1 week (plus 3 or more):
1. Distractability
2. Indiscretion or irresponsible
3. Grandiosity
4. FLight of ideas
5. Activity (increased goal directed activit)
6. Sleep (decreased)
7. Talkativeness (pressured speech)

Question 3

How long do episodes last?

Answer 3

Manic: 1 week
Depression: 2 weeks

Question 4

What are the classifications of bipolar disorders?

Answer 4

1. Bipolar 1: manic episode
2. Bipolar 2: hypomanic episode + major depressive episode
3. Cyclothymic disorder: 2 yr of subsyndromal mood cycling
4. bipolar (NOS: not otherwise specified)

Question 5

What is the criteria for hypomania?

Answer 5

1. Same as mania without functional impairment
2. 4 days
3. Absence of psychosis

Question 6

How do we diagnose bipolar?

Answer 6

1. DSM categorical diagnosis (screenign)
2. Non-DSM features: exam findings, course of illness, prabilistic approach
3. Collateral info

Question 7

How do we screen for bipolar?

Answer 7

Mood disorder questionaire (MDQ):
1. 13 questions based off of DSM criteria
2. Fairly sensitive
3. Takes about 5 minutes
4. Screen every patient with depression

Question 8

What is the DSM 5 diagnosis for bipolar 1?

Answer 8

1. One or more Manic Episode or Mixed Manic Episode
2. Zero, Minor or Major Depressive Episodes often present
3. May have psychotic symptoms

Question 9

What is the DSM 5 diagnosis for bipolar 2?

Answer 9

1. At least one or more Major Depressive Episode
2. One or more Hypomanic Episode
3. No full Manic or Mixed Manic Episodes, no psychotic features

Question 10

What are the alternative diagnosis for bipolar?

Answer 10

1. MDD
2. ADHD
3. Normal mood swings
4. Schizoaffective disorder
5. Schizo/delusional disorder
6. Substance induced bipolar

Question 11

What is the goal for bipolar tx?

Answer 11

1. Reduction of current sx
2. Prevention of relapse
3. No cure

Question 12

psychotherapies for bipolar?

Answer 12

1. Psycho-Education
2. Family Interventions
3. Multifamily Psycho-education Groups (MFPG)
4. Cognitive-Behavioral Therapy (CBT)
5. RAINBOW Program
6. Interpersonal and Social Rhythm Therapy (IPSRT)
7. Schema-focused Therapy
8. Light Therapy
9. Electro-Convulsive Therapy (ECT) & Repeated Transcranial Magnetic Stimulation (r-TMS)
10. Circadian Rhythm- Melatonin
11. Nutritional Approaches- Omega-3 Fatty Acids
12. Medication

Question 13

Medications used for bipolar?

Answer 13

1. Lithium (mood stabilizers)
2. Anticonvulsants (valproate, carbamazepine, lamotrigine)
3. SGA (aripiprazole, olanzapine, combination olanzapine and fluoxetine, lurasidone, paliperidone, quetiapine, risperidone, and ziprasidone)
4. Antidepressants

Question 14

What is the first line for any phase of BP?

Answer 14

Mood stabilizer (lamictal, lithium)

Question 15

Indication for classical AD?

Answer 15

Triggers mania don’t use

Question 16

Indication for atypical AD and SSRI?

Answer 16

Wellbutrin and SSRI don’t cause a switch to mania

Question 17

SGAs for acute depressive episodes?

Answer 17

quetiapine and olanzapine (also combo olanzapine-fluoxetine had greater effect than mono)

Question 18

Tx for acute bp mania?

Answer 18

1. Lithium (mood stabilizer)
2. Valproic acid
3. Carbamexapine XR
4. Atypical antipsychotics

Question 19

What is a good option for more depression prone patients?

Answer 19

Lamotrigine

Question 20

Useful for frequent relapse?

Answer 20

Log acting injectables: risperidone IM Q2W

Question 21

Relapse prevention tx?

Answer 21

Olanzapine and aripiprazole

Question 22

Alt first line from lithium?

Answer 22

Valproate

Question 23

Lithium

Indication, Moniotring

Answer 23

Indication: protects from suicide, acute mania and maintencace
Monitoring: target (0.6-1.2 mEq/L)
* Toxic: ≥1.5 mEq/L
* Sz: ≥2.5
* Check levels 5 days after any dose increase
* Monitor every 6 months in stable patients
* Sweating a lot can affect levels

Question 24

Lithium ADR?

Answer 24

Lithium side effects
Movement in the form of tremors in hands
Nephrotoxicity
Obesity- weight gain /hypothyroidism
Pregnancy defects

Question 25

DDI of litium?

Answer 25

1. NSAIDs, ACE inhibitors and diuretics, can increase serumlithium concentrations
2. Theophylline and caffeine lower levels
3. SS with SSRI, SNRI, Linezolid, triptans

Question 26

Lithium monitoring?

Answer 26

Question 27

Valproate

Indication

Answer 27

Indication: Acute maniac episodes, maintenance mainly
ADR: GI discomfort can switch to ER, Fetal neural tube defects

Question 28

Valproate monitoring

Answer 28

Question 29

Carbamazepine

Indication

Answer 29

Indication: acute maniac episodes
ADR: Constipation, SJS

Question 30

Lamotrigine

Indication, ADR

Answer 30

Indication: acute depression, monotherapy or combo (first line) safer in regnancy
ADR: RASH, menstrual irregularities, tinnitus, SJS

Question 31

APs used for BP?

ADR

Answer 31

Olanzapine and quetiapine (bipolar depression)
Risperidone (long acting inj) manotherapy or as adjunct (lithium or valproate for maintenance tx

ADR: weight gain, DM, hyperprolactimeia, EPS

Question 32

Symbyax

Indication, ADR

Answer 32

Indication: bipolar depression (olanzapine prevent a switch to mania)
Counseling: HS due to olanzapine sedation

Question 33

Advantages and disadvantages of Symbyax?

Answer 33

Advantage: Not more expensive than combo given separately
Disadvantages: potential overuse of olanzapine (sedation and weight gain)

Question 34

Montioring for SGA

Answer 34

Question 35

BZD

Indication

Answer 35

Indication: Acute mania, adjunct to mood stabilizers