IC13 Bipolar Disorder

Question 1

describe bipolar disorder

Answer 1

Lifelong, cyclical mood disorder

Question 2

Illness duration dominated by

Answer 2

depressive episodes (depressive state in bipolar is more depressive than in MDD)

Question 3

pt with bipolar are more likely to…

Answer 3

commit suicide (15x more likely)

Question 4

1st episode presentation

Answer 4

mania in males, depression in females

Question 5

Type of delusions with bipolar mania

Answer 5

grandiose

Question 6

primary cause of bipolar mania

Answer 6

drug induced - antidepressants (typically in the initial few days-2 weeks)

Question 7

Medical conditions causing mania

Answer 7

• CNS disorders (brain tumor, stroke, head injuries, multiple sclerosis)
• Endocrine or hormonal dysregulation: Cushing’s disease (increase cortisone), hyperthyroidism (increase TH → mania), hypothyroidism (decrease TH → depression)

Question 8

Medications causing mania

Answer 8

• Alcohol intoxication
• Drug withdrawal states (alcohol, antidepressants, barbiturates, benzodiazepines, opioid)
• Antidepressants
• DA-augmenting agents (CNS stimulants : amphetamines)
• NE-augmenting agents (beta-agonist, NE reuptake inhibitors)
• Steroids
• Thyroid preparations
• Pseudoephedrine

Question 9

Key feature of bipolar disorder is…

Answer 9

hx of mania/hypomania not caused by any other conditions

Question 10

Sx of mania

Answer 10

abnormal and persistently elevated/ irritable mood: D.I.G.F.A.S.T
- Distractibility
- Irresponsible (overindulgence)
- Grandiose
- Flight of ideas
- Agitation
- Sleep reduced
- Talkativeness

Question 11

Manic episode is defined as

Answer 11

at least 3 sx + elevated/expansive mood (or 4 sx if mood is only irritable)

Question 12

mania vs hypomania

Answer 12

• Manic: sx ≥1 week (functional impairment)
• Hypomanic: sx ≥4 days (no functional impairment, no psychosis)

Question 13

Important assessment before starting pt on meds

Answer 13

• Mental State Exam (MSE) to assess suicidal/homicidal ideations and risks
• Labs and other investigations (FBC, U/E/Cr, LFTs, TFTs, pregnancy): to exclude other medical conditions
• PGx: HLA-B1502 genotype test mandatory before starting carbamazepine

Question 14

Goals of tx

Answer 14

reduce frequency, severity & duration of mood episode, prevent suicide

Question 15

Non-pharm

Answer 15

• Education: recognise early S/S of mania and depression
• Psychotherapy/CBT — only when pt is in listening mood
• Stress reduction techniques
• Sleep hygiene

Question 16

Adjunct tx for mania

Answer 16

Short course (~3-5 days) PRN benzodiazepine
- to help pt relax and sleep, taper off when condition improved and mood stabiliser optimised

Question 17

when to start mood stabilisers

Answer 17

start ASAP dont wait (can take tgt with BZD)

Question 18

for bipolar mania, what mood stabilisers are used?

Answer 18

Lithium, valproate, FGA/SGA (Olanzapine, Quetiapine, Risperidone, Aripiprazole, Haloperidol)

Question 19

for bipolar depression, what mood stabilisers are used?

Answer 19

Lithium, SGA (quetiapine, olanzapine + fluoxetine), lamotrigine

Question 20

CI of valproate

Answer 20

pregnancy

Question 21

does lamotrigine treat mania?

Answer 21

no

Question 22

can antidepressant be used for bipolar depression? what combination?

Answer 22

yes only as combination: olanzapine + fluoxetine

Question 23

SE of lithium

Answer 23

(HPENT)
1. fine to coarse tremors
2. polyuria
3. HYPOTHYROIDISM
4. cardiac effects (ECG changes)
5. nausea
- weight gain, fatigue, cognitive impairment, diabetes insipidus (make too much urine)

Question 24

CL of lithium

Answer 24

not affected by liver, 100% cleared in the kidneys

Question 25

Sx of lithium toxicity (>1.5mEq/L)

Answer 25

GI SE: nausea, vomiting CNS SE: lethargy, confusion, coarse hand tremors, slurred speech, coma

Question 26

Lithium DDI

Answer 26

STAND up - Sodium depletion - Thiazides - ACEi/ARBs — severe increase in Li levels - NSAIDs - Dehydration

Question 27

SE of valproate

Answer 27

SJS/TEN, thrombocytopenia, pancreatitis, increase weight

Question 28

valproate and lamotrigine DDI

Answer 28

Risk of SJS with lamotrigine (valproate decrease CL of lamotrigine)

Question 29

SE of carbamazepine

Answer 29

- SJS/TEN - Agranulocytosis with clozapine

Question 30

PK of carbamazepine

Answer 30

induces own metabolism and that of other drugs

Question 31

Lamotrigine SE

Answer 31

- Less sedation and less weight gain than other drugs listed - Risk of SJS with valproate (lamotrigine half life increased in hepatic impairment and DDI with valproate)

Question 32

Lithium TDM

Answer 32

take samples 12hrs after previous dose. 5-7 days after initiation or change dose.

Question 33

valproate TDM

Answer 33

trough sample needed (sample drawn morning before 1st dose of the day). At least 2-3 days after initiation or change dose.

Question 34

carbamazepine TDM

Answer 34

trough sample needed (sample drawn morning before 1st dose of the day). At least 2-4 weeks to reach steady state (autoinduction effect)

Question 35

tests before starting mood stabilisers

Answer 35

- pregnancy test (VPA) - SJS/TEN (lamotrigine, VPA, carbamazepine) - HLAB1502 (carbamazepine) - low Na/ renal panel (Li toxicity)

Question 36

Mx of recurrent depressive episides

Answer 36

long term Li+, quetiapine, olanzapine + fluxoetine

Question 37

Mx of disorder with rapid cycling (≥4 mood ep per year)

Answer 37

avoid antidepressants/ stimulants (worsen mania) - optimise valproate, lithium

Question 38

choice of drug for pregnancy

Answer 38

- avoid VPA - safe choice: quetiapine, olanzapine, risperidone

Question 39

choice of drug for liver impairment

Answer 39

Li+

Question 40

choice of drug for renal impairment

Answer 40

valproate

Question 41

choice of drug for suicidal behaviour

Answer 41

Li

Question 42

choice of drug for aggression/ violence

Answer 42

optimise dose of lithium or valproate, consider adding antipsychotics (IM antipsychotics first then switch to PO)

Question 43

evaluation of tx response

Answer 43

Monitor target sx (mood sx), compliance