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Collège royal > Maladie Affective Bipolaire > Flashcards

Maladie Affective Bipolaire Flashcards

1
Q

what is the estimated lifetime prevalence of illness across bipolar I, II and subthreshold bipolar disorder subtypes according to the world mental health survey

A

2.4%

(1.5% 12 month prevalence)

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2
Q

what is the lifetime prevalence of bipolar I

A

0.6%

(0.4% 12 month prevalence)

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3
Q

what is the lifetime prevalence of bipolar II

A

0.4%

(0.3% 12 month prevalence)

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4
Q

what are the 3 “age of onset” age ranges for BDI

A

early onset (large/42%)–> around age 17 +/- 3 years

middle onset (smaller/26%)–> 24 years +/- 5 years

late onset (34%)–> 32 +- 12 years

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5
Q

what comorbid conditions/symptoms are associated with earlier age of onset

A

longer delay to treatment

greater depressive severity

higher levels of anxiety and substance use

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6
Q

in which cases should organic mania be considered and investigated

A

when mania onset occurs after age 50

(though manic episodes can occur for first time after age 50)

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7
Q

for what % of the time are people with BD generally unable to maintain proper work role function

A

about 30% of the time or mroe

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8
Q

why do we are about preventing mood episodes in BD

A

because on average the risk of recurrence increases with # of previous episodes

also–> number of previous episodes is associated with increased duration and symptomatic severity of subsequent episodes

also–> number of episodes is associated with lower threshold for developing further episodes

also–> increased risk of dementia with more episodes

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9
Q

what are the three broad clinical stages in the staging system for BD

A
  1. individuals at increased risk for developing BD due to family history as well as certain subsyndromal symptoms predictive of conversion to full BD
  2. patients with fewer episodes and optimal functioning in interepisodic periods
  3. patients with recurrent episodes as well as decline in functioning and cognition

*heterogeneity in BD has prevented clinical use of staging systems

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10
Q

list 10 features of depression that may increase suspicion of bipolarity

A
  1. earlier age of illness onset
  2. highly recurrent depressive episodes
  3. family history of BD
  4. depression with psychotic features
  5. psychomotor agitation
  6. atypical depressive symptoms
    –hypersomnia
    –hyperphagia
    –leaden paralysis
  7. postpartum depression and psychosis
  8. past suicide attempts
  9. antidepressant induced manic symptoms
  10. rapid cycling
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11
Q

what is the second most common misdiagnosis for BD

A

schizophrenia and other psychotic disorders –> occurs as initial diagnosis in asm any as 30% of patients

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12
Q

what is a good screening tool for flagging patients who may have signs/symptoms of BD

A

the Mood Disorders Questionnaire (MDQ)

this is a validated self report instrument

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13
Q

what % of identified patients with BD die by suicide

A

6-7%

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14
Q

what % of patients with BD worldwide report SI

A

43%

21% have plan

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15
Q

what % of patient with BD have attempted suicide in the past year worldwide

A

16%

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16
Q

list 9 factors that have been significantly associated with suicidal ATTEMPT in BD

A
  1. female sex
  2. younger age of illness onset
  3. depressive polarity of first illness episode
  4. depressive polarity of current or more recent episode
  5. comorbid anxiety disorder
  6. comorbid SUD
  7. comorbid cluster B/borderline PD
  8. first degree family history of suicide
  9. previous suicide attempts
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17
Q

what are the only two risk factors that have been significantly associated with suicide DEATHS in BD

A
  1. male sex
  2. first degree family history of suicide

*older age also results in a higher degree of lethality of attempts with higher ratio of death:attempts

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18
Q

what % of suicides in BD occur DURING an inpatient stay

A

14%

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19
Q

what % of suicides in BD occur within 6 weeks of discharge

A

26%

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20
Q

for which psychosocial interventions is there positive evidence in the maintenance phase of BD

A

CBT (2nd line)

family focused therapy (2nd line)

interpersonal and social rhythm therapy (3rd line)

peer support (3rd line)

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21
Q

what psychosocial intervention is first line in maintenance phase of BD

A

psychoeducation

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22
Q

how many sessions of individual psychoeducation would be required to be a first line intervention for relapse prevention in BD?

A

at least 5 sessions

level 2 evidence for relapse prevention

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23
Q

is CBT recommended in acute bipolar depression

A

yes–> second line–> level 2 evidence

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24
Q

how does interpersonal and social rhythm therapy differ from IPT

A

includes regulation of social and sleep rhythms specifically targeted to the bipolar population

24 individual sessions over 9 months

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25
Q

what is the DSM V definition of agitation

A

“excessive motor activity associated with feeling of inner tension”

26
Q

list the 4 first line agents recommended for management of agitation in BD

A

aripiprazole IM (9.75 mg)

lorazepam IM (2mg)

loxapine inhaled (5mg)

olanzapine IM (2.5mg)

27
Q

list 6 second line agents (or combinations) recommended for managing agitation in mania

A

asenapine

haloperidol IM

haloperidol + midazolam

haloperidol + promethazine

risperidone

ziprasidone

28
Q

should monotherapy be tried before combination therapy?

A

not necessarily–> treating clinician makes the decision for mono or combo therapy

*based on rapidity of response needed, whether hx previous partial response to monotherapy, severity of mania, tolerability concerns with combo therapy and willingness of patient to take combo therapy

29
Q

which works faster for acute mania, mono or combo therapy

A

combo

30
Q

List the 4 first line combination therapies for acute mania IN ORDER

A
  1. Quetiapine + lithium/divalproex
  2. Aripiprazole + lithium/divalproex
  3. Risperidone + lithium/divalproex
  4. Asenapine + lithium/divalproex
31
Q

list second line treatments (combo + mono) for acute mania IN ORDER

A
  1. olanzapine
  2. carmabazepine
  3. olanzapine + lithium/divalproex
  4. lithium + divalproex
  5. ziprasidone
  6. haloperidol
  7. ECT
32
Q

what is a mnemonic for second line treatments for acute mania

A

Only Cows On LSD Zipline Happily Evermore

33
Q

with which treatment for acute mania is there a concern for depressive switch

A

haldol

34
Q

which first line treatments for acute mania have data for treating acute depression as well

A

lithium

quetiapine

divalproex

cariprazine

35
Q

which first line treatments for acute mania have data for preventing depression

A

lithium

quetiapine

divalproex

asenapine

36
Q

which first line agents for treatment of acute mania have evidence for preventing mania

A

all EXCEPT cariprazine

37
Q

which first line agent for acute mania has the most tolerability concerns in the acute period

A

quetiapine

38
Q

which first line agents for acute mania (3) have the most safety concerns in the maintenance period

A

lithium

quetiapine

divalproex

39
Q

which first line combination therapies for acute mania have the most safety concerns in the maintenance period

A

quetiapine + lithium/divalproex

risperidone + lithium/divalproex

*significant impact on treatment selection

40
Q

which combination therapy for acute mania seems to have the best tolerability and safety profile in the maintenance period

A

asenapine + lithium/divalproex

*but this is also ranked fourth in the combo ranking

the next safest/most tolerable is aripiprazole + lithium/divalproex followed by the quetipaine and risperidone combos

41
Q

does ziprasidone treat and/or prevent bipolar deprssion

A

no data for prevention

data shows it does NOT treat bipolar depression

42
Q

does ECT treat and/or prevent bipolar deprssion

A

it seems to do both (level 4 evidence)

43
Q

does haloperidol treat and/or prevent bipolar deprssion

A

data suggests it does NOT prevent

no data with regard to treating bipolar depression

44
Q

when should efficacy of treatment for acute mania be evaluated

A

at the end of weeks 1 and 2 and then treatment options modified accordingly

45
Q

what % of patients presenting with acute mania will respond to monotherapy? in what time frame?

A

50% within 3-4 weeks

46
Q

how does efficacy compare in acute mania treatment between the first line monotherapy agents

A

comparable efficacy

47
Q

for those initiating or switching treatments during the maintenance phase, which medications would be considered FIRST line for this phase of bipolar disorder

A

lithium

divalproex

lamotrigine

asenapine

aripiprazole

(monotherapy or in combination)

48
Q

after how long did almost all anti-manic agents separate from placebo in trials

A

after one week

therefore, expect some therapeutic response to antimanic agents within 1-2 weeks

49
Q

which first line anti manic agents that are recommended for monotherapy are NOT recommended for combination therapy

A

paliperidone and ziprasidone

due to lack of evidence for additional efficacy

50
Q

what % of patients is it estimated will respond to ECT as antimanic treatment

A

up to 80%

51
Q

what non-AP or mood stabilizer has level 2 evidence for treatment of acute mania and is third line

A

tamoxifen

(downgraded because of the risk of uterine cancer and lack of clinical experience DESPITE EVIDENCE FOR EFFICACY)

52
Q

what neurostimulation therapy, other than ECT, can be considered as third line in treatment of acute mania

A

rTMS

53
Q

name a non pharmacologic intervention that has level 3 evidence for treatment of acute mania when combined with other anti manic agents

A

glasses that block blue light

54
Q

when would you usually choose divalproex over lithium when treating mania

A
  1. person has multiple prior episodes
  2. predominant irritable or dysphoric mood
  3. comorbid substance use

and/or

  1. those with hx head trauma
55
Q

does the presence of anxious distress during a manic episode give any prognostic information

A

yes–>

predictor of poor outcome

i.e greater severity of manic symptoms, longer time to remission, more reported side effects of medication

56
Q

are there specific agents recommended to treat anxious distress is mania

A

not studies specifically examining this–> anxious distress tends to improve as the mood episode improves

post hoc analyses:
divalproex
quetiapine
olanzapine
may be helpful

57
Q

what % of manic episodes are characterized by the presence of psychosis

A

at least HALF

58
Q

does it matter whether psychotic symptoms are mood congruent or incongruent in BD

A

if psychosis is mood incongruent seem t have more severe illness with poorer long term prognosis

59
Q

is there any evidence of superiority of any first line antimanic monotherapy compared to any other when psychotic features are present?

A

no

also no evidnece that any particular combo therapy is better for psychotic features

**clinical experience suggests combo therapy of atypical AP + li/dvp more appropriate for manic patients with mood-incongruent psychotic features

60
Q

what % of patients with bipolar I have rapid cycling BD

A

about 30%

61
Q

what three other factors are often associated with rapid cycling in BD

A

hypothyroidism

antidepressant use

substance use

Collège royal (18 decks)

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