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CNS Module > Bipolar Disorder > Flashcards

Bipolar Disorder Flashcards

(44 cards)

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1
Q

Bipolar Disorder, definition

A

Cyclical disorder characterized by fluctuations in mood, energy, and activity

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2
Q

Bipolar 1

A

Any manic episodes, or mixed episodes + major depressive disorder

Often precipitated from substance abuse. Watch out for antidepressant use (can be diagnostic if manic episodes emerge during antidepressant treatment - medication OR ECT)

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3
Q

Bipolar 2

A

Recurrent major depressive episodes, with at least one hypomanic episode

NOT precipitated from substance abuse

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4
Q

Definition of mania

A

AKA manic: includes symptoms of psychosis, hallucinations, delusions

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5
Q

Definition of hypomania

A

Less-severe mood elevation

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6
Q

Is mania or hypomania more likely to require hospitalization?

A

Mania

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7
Q

What is Cyclothymic Disorder?

A

Constant fluctuations between hypomania and depression (not clinically major depressive disorder)

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8
Q

Can worsening manic symptoms emerging from antidepressant treatment be diagnostic for bipolar 1 or bipolar 2?

A

Bipolar 1 only! Antidepressant treatment via medications or ECT can worsen symptoms of mania*. Mania only occurs in Bipolar 1, therefore this phenomenon can only be diagnostic for bipolar 1.

Side note: if a full hypomanic episode emerges during antidepressant treatment, this is sufficient diagnostic evidence for bipolar 2.

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9
Q

A random patient MA is refusing to eat and in a catatonic state (immobile, lack of movement). What is the best treatment for this patient?

A

ECT! Electrical conduction alterations over the course of several treatments for this patient population has proven more helpful than medication alone.

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10
Q

Definition of mixed symptoms

A

Meets criteria for both major depressive episodes and manic episodes changing everyday for 1 week

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11
Q

What is rapid cycling?

A

More than 4 polar episodes (manic, hypomanic, depressive, or mixed) within 1 year. May require hospitalization

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12
Q

What are the four domains of bipolar disorders?

A
  1. Manic or hypomanic behavior (euphoria, grandiosity, excessive libido, recklessness)
  2. Psychosis (delusions, hallucinations)
  3. Dysphoria (depression, anxiety, irritability, suicide)
  4. Cognition (racing thoughts, distractibility)
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13
Q

Psychiatric co-morbid conditions to bipolar disorder

A 
Personality disorders
Alcohol or substance abuse
Anxiety and panic disorders
ADHD
OCD
Social phobias
Eating disorders
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14
Q

Medical co-morbid conditions to bipolar disorder

A 
Migraine
MS
Cushing's
Brain tumor
Head trauma
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15
Q

General first-line treatment combination for bipolar disorders

A

Antipsychotic + mood stabilizer

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16
Q

FDA-labeled indication for lithium

A

Acute*** and maintenance treatment of mania

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17
Q

How do we monitor efficacy of lithium?

A

Trough concentration.

  • 0.6-1.2 mEq/L for acute mania episodes
  • 0.6-1.0 mEq/L for maintenance
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18
Q

At what trough concentration can people experience lithium toxicity? What are the symptoms?

Study These Flashcards
A

> 1.5 mEq/L, more likely as it approaches >2.5 mEq/L

Symptoms: severe vomiting and diarrhea, tremor, ataxia, seizures, cardiac arrhythmias, coma, kidney damage

19
Q

Treatment for lithium toxicity

Study These Flashcards
A

Discontinue lithium, IV hydration, osmotic diuresis or hemodialysis

Keep watching and monitoring! Lithium can take even longer to leave CNS than the serum concentrations show.

20
Q

Main adverse effect to lithium? How do we treat it?

What other common adverse effects are common with lithium?

Study These Flashcards
A

Polyuria, treat with HCTZ (paradoxical effect)

Other common effects include GI upset, tremor, hypothyroidism, glucose dysfunction, weight gain

21
Q

Most common drug interactions to lithium

Study These Flashcards
A

Increase [lithium] - thiazides, NSAIDs, ACEis, Loops

Decrease [lithium] - caffeine

22
Q

Valproic acid and divalproex indication

Study These Flashcards
A

Acute treatment of mania only. Particularly useful for patients with rapid-cycling, mixed mood, substance abuse

Maintenance treatment is off label. Along with migraine prophylaxis

23
Q

What is the goal serum concentration for divalproex?

Study These Flashcards
A

50-125 mcg/mL

24
Q

What black box warnings are associated with both valproic acid and divalproex?

Study These Flashcards
A

Hepatitis, pancreatitis, mitochondrial disease

25
What are the most common drug interactions with valproic acid and divalproex?
Lamotrigine and antidepressants
26
Side effects for valproic acid and divalproex
GI, tremor, weight gain, thrombocytopenia, drowsiness
27
Carbamazepine FDA indication
Acute treatment of mania *not first line due to tolerability and drug interactions* Off-label: maintenance treatment, neuropathic pain.
28
Carbamazepine drug interactions | *know these*
``` Anticonvulsants Antidepressants Antipsychotics Oral Contraceptives Antiretroviral drugs Benzodiazepines Macrolide antibiotics Azole antifungals Grapefruit juice ```
29
What does it mean that carbamazepine is an auto-inducer and why is that important?
An autoinducer means that carbamazepine is both a substrate and inducer for several CYP enzymes. After prolonged use, the half life of carbamazepine can actually decrease, requiring higher concentrations
30
What is the benefit to using oxcarbazepine compared to carbamazepine?
There are fewer drug-drug interactions, however it causes more GI side effects and increases the risk of hyponatremia.
31
What is the goal serum concentration for carbamazepine
4-12 mcg/mL
32
What is the role of benzodiazepines in treatment of bipolar disorders?
Used to stabilize patients during acute manic episodes. Usually PRN dosing inpatient management- not home use
33
What is lamotrigine, how is it dosed, and how is it used for bipolar treatment?
Mood stabilizing drug. Can cause SJS, so slowly titrate the dose up. So it makes sense that this medication should only be used for maintenance treatment.
34
What to do if patient is on divalproex and lamotrigine was started without catching the interaction?
Decrease the lamotrigine dose by 50%
35
What is the role of Second Generation Antipsychotics in the treatment of bipolar disorders?
SGA's are first line treatment and should be used even if there are not any current psychotic symptoms Remember: antipsychotics + mood stabilizers = 1st line
36
Which SGA's are best for mania?
Remember, the ZA crazy Queen ORCA Z - ziprasidone A - aripiprazole crazy = mania Q - quetiapine O - olanzapine R - risperidone C - cariprazine A - asenapine
37
Which SGA's are best for depression?
Quetiapine Olanzapine+fluoxetine Lurasidone
38
What is the role of antidepressants in treatment of bipolar disorders?
Use not recommended - can precipitate either mania or hypomania (remember potential use in diagnosing of the disorder). Use should be reserved as a list ditch effort with a mood stabilizer
39
How does treatment change in pediatric populations?
Lithium can be used 12 years and up. Maybe carbamazepine and divalproex Aripiprazole, asenaprine, risperidone, olanzapine, quetiapine can be used 10 years and older More sensitive to adverse effects, start with low dosages and titrate up
40
How does treatment change in geriatric populations?
Shoot for lower serum concentrations Lithium = 0.4/1 mEq/L Carbamazepine = 4=12 mcg/mL Valproic acid = 25-100 mcg/mL
41
How does treatment change in pregnancy and postpartum populations?
Although there is teratogenic risk, the risk of bipolar relapse is more harmful for the pregnancy. Generally recommendedd to NOT discontinue despite teratogenic properties. Can consider First Generation Antipsychotics because they have less teratogenicity, but there is not as much evidence for use in bipolar disorders.
42
Acute treatment of manic episode
1st line = Lithium or VPA/DVP + SGA (ZA crazy Queen ORCA) - Can't use combination? Make sure suicidal patients receive lithium, psychotic patients receive SGA. - Optimize treatment before augmenting Alternative 1st line = Olanzapine, carbamazepine, or oxcarbazepine 2nd line = Consider adding another mood stabilizer
43
Acute treatment of depressive episode
1st line = monotherapy lithium, quetiapine, lurasidone, or lamotrigine - if suicidal, use lithium Alternative 1st line = olanzapine/fluoxetine, valproic acid, divalproex, or carbamazepine 2nd line = Add a mood stabilizer
44
Maintenance treatment of bipolar disorder
After stabilization for 4-6 months, simplify regimen by lowering doses/serum level goals. Taper off medications until using one agent if at low risk of relapse.

CNS Module (9 decks)

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