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Bipolar Disorder Flashcards

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1
Q

Risks factors of bipolar disorder

A
  1. Genetics
  2. Treatment induced
  3. General medical conditions
  4. History of trauma
  5. Physical stressors
  6. Seasonal changes
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2
Q

What treatments induces bipolar disorder?

A
  1. Antidepressants (induces mania, typically in initial few days to 2 weeks)
  2. ECT
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3
Q

Medications/drugs that induces mania (1)

A

Drug-withdrawal states (alcohol, α2-agonists, antidepressants, barbiturates, benzodiazepines, opiates)

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4
Q

Medications/drugs that induces mania (2)

A

Antidepressants (MAOIs, TCAs, 5-HT and/or NE and/or DA reuptake inhibitors, 5-HT antagonists)

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5
Q

Medications/drugs that induces mania (3)

A

DA-augmenting agents (CNS stimulants: amphetamines, cocaine, sympathomimetics; DA agonists, releasers, and reuptake inhibitors)

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6
Q

Medications/drugs that induces mania (4)

A

NE-augmenting agents (α2-antagonists, ß- agonists, NE reuptake inhibitors)

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7
Q

Medications/drugs that induces mania (5)

A

Steroids (anabolic, adrenocorticotropic
hormone, corticosteroids)

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8
Q

Medications/drugs that induces mania (6)

A

Thyroid preparations (T3 or T4)

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9
Q

Medications/drugs that induces mania (7)

A

OTC decongestant (pseudoephedrine)

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10
Q

Medical conditions that induces mania (1)

A

CNS disorders (brain tumour, stroke, head injuries, multiple sclerosis, SLE)

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11
Q

Medical conditions that induces mania (2)

A

CNS Infections (encephalitis, neurosyphilis, sepsis, human immunodeficiency virus)

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12
Q

Medical conditions that induces mania (3)

A

Electrolyte or metabolic abnormalities (calcium
or sodium fluctuations, hyper- or hypoglycemia)

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13
Q

Medical conditions that induces mania (4)

A

Metabolic dysregulation (Addison’s disease, Cushing’s disease, hyperthyroidism (mania), hypothyroidism (depression), menstrual-related or pregnancy-related or perimenopausal mood disorders)

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14
Q

Medical conditions that induces mania (5)

A

Vitamins and nutritional deficiencies (essential amino acids, fatty acids, Vit B)

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15
Q

Key feature of bipolar disorder is _________.

A

History of mania/hypomania not caused by other conditions or substances.

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16
Q

“High mood (manic)” symptoms are _______.

A

Abnormal & persistently elevated/expansive/irritable mood

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17
Q

“High mood (manic)” symptoms - Digfast

A
  1. Distractibility & easily frustrated
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18
Q

High mood (manic)” symptoms - dIgfast

A
  1. Irresponsibility and erratic uninhibited behaviour (activities that are pleasurable but high risk of serious consequences)
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19
Q

High mood (manic)” symptoms -diGfast

A
  1. Grandiosity (inflated self esteem)
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20
Q

High mood (manic)” symptoms - digFast

A
  1. Flight of ideas (racing thoughts)
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21
Q

High mood (manic)” symptoms - digfAst

A
  1. Activity increased
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22
Q

High mood (manic)” symptoms - digfaSt

A
  1. Sleep: need decreased
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23
Q

High mood (manic)” symptoms - digfasT

A

Talkativeness

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24
Q

Duration of mood episodes that is considered mania

A

Symptoms ≥ 1 week

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25
Duration of mood episodes that is considered hypomania
Symptoms ≥4 days
26
How many symptoms of DIGFAST is considered a manic episode?
At least 3 symptoms + elevated/expansive mood 4 symptoms if mood is only irritable
27
Bipolar I = _______ ± depressive episodes
Mania
28
Bipolar II = ______ ± depressive episodes
Hypomania
29
General assessments (1)
History of present illness
30
General assessments (2)
Psychiatric hx - Any history of manic/ hypomanic episodes? (starting an antidepressant may cause “manic switch” in patients with underlying bipolar disorder)
31
General assessments (3)
Complete medical & medication history Reassess adherence to medications on every visit
32
General assessments (4)
Family, social, forensic, developmental & occupational history
33
General assessments (5)
Physical & neurological exam
34
General assessments (6)
Mental State Exam (MSE) for accurate diagnosis * Assess for suicidal/homicidal ideations and risks * Reassess MSE on every interview to evaluate efficacy & tolerability
35
General assessments (7)
Labs Vital signs, weight & BMI, FBC, U/E/Cr, LFTs, TFTs, ECG,, fasting blood glucose, lipid panel, urine toxicology; pregnancy test
36
General assessments (6)
Other investigations To exclude general medical conditions or substance-induced/withdrawal symptoms, e.g. delirium/ psychosis/ depression/ mania/ anxiety/ insomnia/ thyroid dysfunction/ diabetes
37
Which medicine requires genotype testing?
HLA-B*1502 prior to starting Carbamazepine
38
Gold standard of rating scales
Young Mania Rating Scale (YMRS) - Rater administered, not used clinically
39
Goals of treatment (1)
1. Reduce frequency, severity & duration of mood episodes
40
Goals of treatment (2)
2. Prevent suicide
41
Goals of treatment (3)
3. Maximise adherence to therapy
42
Goals of treatment (4)
4. Minimise adverse effects i.e. employ medications with the most acceptable tolerability and fewest drug interactions
43
Goals of treatment (5)
Acute Treatment Phase: - Eliminate mood episode with remission of symptoms
44
Goals of treatment (6)
Maintenance/ Continuation Treatment Phase: - Reduce frequency, duration & severity of recurring mood episodes. - Reduce suicidal ideation or attempts – Regain psychosocial functioning – Avoidance of stressors or substances that may precipitate an acute mood episode
45
Non-pharmacological (1)
Recognising early signs & symptoms of mania and depression
46
Non-pharmacological (2)
Psychotherapy
47
Non-pharmacological (3)
Stress reduction techniques
48
Non-pharmacological (4)
Sleep hygiene
49
Treatment framework
a) Short course of PRN benzodiazepines b) Start mood stabiliser for acute treatment (& maintenance therapy)
50
What is the short course of PRN benzodiazepines for?
Help patient relax & sleep, within hours. Taper off when condition improved and mood stabiliser optimised.
51
Which drug has the strongest evidence to reduce suicide?
Lithium
51
Which drug has the strongest evidence to reduce suicide?
Lithium
52
Onset of effectiveness for stabilising mood
About 3-5 days
53
Initial monotherapy for mania (1)
Antipsychotics SGA: Olanzapine, Quetiapine, Risperidone, Aripiprazole FGA: Haloperidol
54
Initial monotherapy for mania (2)
Lithium - 1st line for maintenance & relapse/suicide prevention
55
Initial monotherapy for mania (3)
Least preferred - Valproate Avoid in pregnancy/women with childbearing potential
56
Combination therapy for mania
Lithium ± Valproate ± Antipsychotics
57
Initial monotherapy for bipolar & depression (1)
Lithium - 1st line for maintenance & relapse/suicide prevention
58
Initial monotherapy for bipolar & depression (2)
Antipsychotics - Quetiapine, Olanzapine + Fluoxetine combination
59
Initial monotherapy for bipolar & depression (3)
Lamotrigine - Does not have any manic properties
60
MOA of Lithium
Normalise/inhibits secondary messenger systems, may reduce PKC Decreases 5HT reuptake and DA release
61
Dosing of Lithium
Initial: 400-800mg/day Max: 1.8g/day
62
Target concentration of Lithium
Steady state in 5 days Acute mania = 0.8 – 1.0 mEq/L Maintenance = 0.6-1.0 mEq/L
63
More serious side effects of Lithium
Tremours Polyuria Hypothyroidism ECG changes Nausea
64
Lithium toxicity with:
STAND 1. Decreased Na 2. Thiazides 3. ACEi/ARBs 4. NSAIDs 5. Dehydration
65
Less serious side effects of Lithium
1. Weight gain 2. Fatigue 3. Cognitive impairment 4. Diabetes insipidus
66
_____ and _____ can enhance renal elimination of Li+
Caffeine Theophylline
67
Lithium has no effect on ___________.
Hepatic metabolising enzymes 100% renal CL
68
Carbamazepine metabolism
CYP3A4 (major), CYP2C8 (minor) Auto-induction of enzymes (start low before titrating)
69
TDM for Lithium
Take samples 12hrs after previous dose 5-7 days after initiation/dose or formulation change 2 times weekly in acute stage Every 3 months in 1st year, subsequently every 306 months
70
TDM for Sodium Valproate
Trough sample (drawn morning before 1st dose) At least 2-4 days after initiation or dose change
71
TDM for CBZ
Trough sample (drawn morning before 1st dose) Every 1-2 weeks during initiation (auto induction takes 2-4 weeks to reach SS) Bi-anually for 1st year, annually after.
72
How long does patient need to be on drug before switching or augmenting?
No response within 2-4 weeks
73
What is considered rapid cycling?
≥4 mood episodes per year
74
Omit Lithium, Anticonvulsants and Benzodiazepines (at least ___ hrs) just before ECT,
12
75
Recurrent depressive episodes require _________, Quetiapine or ‘Olanzapine + Fluoxetine’, Lamotrigine, Lurasidone, or Cariprazine.
Long term Lithium
76
Pregnancy
Avoid Valproate Quetiapine, Olanzapine, Risperidone but monitor for side effects (e.g. gestational diabetes_
77
Breastfeeding
Risk vs Benefit. ALL mood stabilisers are secreted into breastmilk
78
CVD
Valproate: monitor for increased BP & HR, peripheral edema
79
Hepatic impairment
Lithium
80
Renal impairment
Valproate
81
Elderly
Lamotrigine????

54 CNS (13 decks)

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