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Flashcards in Bipolar Disorder Deck (55)
1

Bipolar one disorder

Mania with Major depressive episodes
includes anything where mania results in hospitalization

2

Bipolar two disorder

hypomania with major depressive episodes

3

Mixed episode in bipolar disorder

mania and depression all at the same time

4

rapid cycling in bipolar disorder

4 major depressive or manic episodes in a 12 month period

5

What is Bipolar disorder often misdiagnosed as?
Why?
What happens when it is misdiagnosed this way

Unipolar depression because patients often present with depression and manic episodes are not brought to the attention of the physician
Physician describes antidepressants which can swing patient into a manic episode

6

Diagnosis of a manic episode

At least one week with at least 3/7 symptoms
DIG FAST
Distractibility
Increased activity or psychomotor activity
Grandiosity- inflated self esteem
Flight of ideas
Activities that are dangerous, hypersexual, or goal directed
Sleep- decreased need (1-2 hours/ night)
Talkative or pressured speech

7

Diagnosis of Hypomania

same set of DIG FAST symptoms but alsting at least 4 days
but not severe enough for a marked change in social or functional impairment

8

Epidemiology

average age of onset is 21
first presents in females as depressive episode, males as manic episode

9

Etiology

Most genetic of all psychological disorders
stressful or exciting events can trigger an episode
getting off of the rhythm can also trigger an episode

10

What is suicide rate in untreated bipolar disorder
other issues in untreated

10-20%
higher rate of job loss
divorce, violence, incarceration, and STDs

11

Concurrent social functioning issues

Substance abuse- inc risk of suicide
many patients lack insight into their disease making it hard to tx

12

What is compliance like

50-75% dont maintain their drug regimen
90% relapse

13

What happens if TCA's or SNRI's are given to these patients

Mania or rapid cycling

14

Triggers for Bipolar Episodes

avoid triggers such as sleep deprivation, antidepressants without a mood stabilizer, alcohol

15

Role of ECT in bipolar management

Bilateral ECT is used for acute mania and acute depression.
indicated in drug resistant mania
Pregnancy

16

Role of psycho education in bipolar management

Important for pt to learn to recognize the signs early so that they can take preventative measures

17

Li

Lithium

18

Li MOA

Not well understood

19

Gold standard to tx bipolar disorder is

Li

20

Why is Li the gold standard in bipolar tx

stabilizes acute mania, prevents relapse of mania and depression
does more to prevent mania than prevent depression
decreases suicide rate

21

how does Li compare to other drugs for dealing with depression

Better than many other drugs for dealing with depression in bipolar disorder

22

What is the metabolism/ Pharmacokinetics of Li?
how is it handled in the body

Rapidly absorbed, not metabolized, no protein binding
steady state is reached in 5 days but takes 1-2 weeks to see full effects
Renal excretion

23

Does Li have psychotropic effects in pts who dont have bipolar disorder?

no psychotropic effects

24

What should patients use while waiting for Li take effect

takes 1-2 weeks
should use adjunctive therapy

25

What are the AE of Li

Dose dependent tremor
psoriasis/ rash
weight gain
acne
hypothyroid
GI discomfort (N/V/D, GI pain)

26

What renal or urinary complications can be caused by LI

reduces the ability to concentrate the urine
causes interstitial fibrosis and gloerulosclerosis
dose dependent DI
polydipsia and polyuria

27

How should dif GI AE be handled

N/V and pain are caused by irritation of GI, this is early onset so take it with food or use sustained release or divided dose
Diarrhea is caused by colon irritation from unabsorbed Li --> use liquid or immediate release dosage

28

What are the signs of acute Li intoxication?
How is it avoided?

Seizures, Arrhythmia
GI, coordination issues, cognition issues, permanent neurologic impairments, kidney damage
Maintain adequate Na and fluid intake

29

What drugs increase the level of Li

NSAIDs- interfere with PGE synthesis --> dec elimination
ACE and ARB- RAAS
Thiazide diuretics- inc Li reab in distal tubule b/c inc Na reab

30

What effect does GFR have on serum Li

as GFR dec serum Li increases

31

What is the role fluid and Na balance in Li serum concentration

Dehydration inc Na reab as does low Na --> both inc Li reab so inc Li levels
Hyponatremia and dehydration lead to Li toxicity

32

CI for Li

Renal dysfunction
Pregnancy- Cat D- Ebstein's anomaly
cardiac dysfunction

33

Anticonvulsants used in the tx of Bipolar disorder

Valproate
Carbamazepine/ Oxcarbazepine
Lamotrigine

34

Valproate MOA

enhances GABA to break acute mania and manage mixed mania
Also affects Na channels

35

Indications for Valproate

Superior to Li in mixed mania and rapid cyclers
alternative to Li

36

AE for Valproate

weight gain
PCOD
hepatotoxicity
neutropenia
thrombocytopenia

37

CI for Valproate

pregnancy- causes neural tube defects and lowers IQ

38

What baseline tests should be done before giving someone Li

CBC- b/c may cause thrombocytopenia
SCr and BUN to monitor renal function
Thyroid function test- may cause hypothyroid
Urinalysis- may cause polyuria
Electrolytes

39

What blood tests should be monitored while taking Li

Li levels
CBC
SCr/ BUN
urine TSH

40

what stage of bipolar disorder are higher therapeutic levels of Li required

during acute mania
remember Li has a narrow therapeutic index

41

Carbamazepine/Oxcarbazepine- indications

when Li and Valproate fail

42

Lamotrigine MO

blocks voltage gated Na channels to block excitatory glutamate and aspartate

43

How long does it take to achieve a therapeutic dose

2 months of titrating up

44

Why does it take so long to titrate to a therapeutic dose

AE include Steven's johnson syndrome (toxic necrotizing epidermolysis) and HA. Titrate up to avoid the rash

45

What is the black box warning on Lamotrigine

Steven's Johnson syndrome

46

what effect does valproate have on Lamotrigine levels

Valproate inc Lamotrigine levels

47

Lamotrigine indications

used with Li b/c better at managing the depression but is not effective for stabilizing or preventing mania

48

What drugs are used to treat acute agitations

atypical antipsychotics
BZD- clonazepam, lorazepam
Antidepressants- SSRIs, venlafaxine, buproprion

49

What is the role of atypical antipsychotics in bipolar disorder

fast acting monotx to be used with Li or valproate
the pt may have to be on these long term for mood stabilization
indicated over BZDs in psychosis and acute mania

50

what is the role of BZDs in tx bipolar disorder

used to dec agitation and insomnia- they do not tx the dz

51

What is role of antidepressants in tx of bipolar disorder

use cautiosly and make sure use with a mood stabilizer otherwise it can throw them into mania.
careful with pts with a history of going into acute mania or rapid cyclers when given an antidepressant

52

what is the theory explains why anticonvulsants work

Kindling theory

53

DOC for depression phase of bipolar disorder

Li and Lamotrigine

54

DOC for mixed and rapid cyclers

Valproate and Carbamazepine

55

DOC for pregnancy in bipolar disorder

Antipsychotics
ECT