Mood disorders - Bipolar

Question 1

If SSRI is bad for BPAD, how is the depression managed?

1st line option
2nd line

Answer 1

Need to give an antidepressant WITH an antipyshotic or mood stabiliser

1st line - Fluoxetine + olanzapine
2nd line - quetiapine alone

Question 2

Risk factors of bipolar disorder? (3)

Answer 2

Fx of BPAD or suicide

Substance misuse disorders

earlier age of onset

Question 3

What is the therapeutic range of lithium for BPAD?

Answer 3

0.4 - 1mmol/L

to avoid lithium toxicity

Question 4

What is Mania & the core symptoms

Answer 4

Symptoms that last for more than 7 days
Impairs social function
Has psychotic symptoms (Delusions or hallucinations)

Core symptoms:
Elevated mood
Increased energy

Question 5

What is medication 1st line + 2nd line for ACUTE management of BPAD/mania?

Answer 5

Everyone → stop all medications that may cause symptoms (eg. antidepressants). Short course of benzodiazepines (lorazepam) for sedation.

If Treatment Free → first line = antipsychotic (olanzapine) to stabilise before starting mood stabiliser. Second line = different antipsychotic (haloperidol, quetiapine, risperidone). Third line = add sodium valproate or lithium (lithium not as effective acutely

If already on Treatment → optimise the medication (stop antidepressants), check lithium levels, add an atypical antipsychotic. Short-term benzodiazapines may help (sedation).

Question 6

Epidemiology of bipolar disorder?

Answer 6

Meage age 18-21

Suidice rate is higher

10% had depression who then go on to develop mania (tx cause)

Question 7

Secondary mania may be caused by?
Physical cause
medications?
others?

Answer 7

Organic brain damage - right hemiaphere (can be more common in elderely)

Medication - Levodopa (parkinsonism med) + corticosteroids

Illicid drugs

Hypothyroidiam (akin to depression) and hyperthryoid state (hypomanic)

Question 8

Complications of lithium use

Answer 8

Teratogen (avoid in preggers + children)
Arrythmia (do ecg prior to starting)
CKD
Hypthyroidism

Question 9

Lithium adverse affects (if toxicitiy occurs)

Answer 9

Question 10

What is treatment for rapid cycling BPAD?

Answer 10

Sodium valproate

Question 11

Ebstein’s anomaly

• what medication can cause it
• what does it do

Answer 11

In pregnancy is lithium is given

• congenital heart defect in tricuspid valve for fetus

Question 12

What is Bipolar affective disorder Type 1

Answer 12

Most common

Has mania and depression

Question 13

What blood concentration are we looking for when lithium is prescribed?

• What condition may precipitate lithium toxicity

Answer 13

0.6-0.8 mmol.L

Toxicity is 1.2<

This can be precipitated by any renal dysfunction (dehydration, failure, thiazide diuretics, ACE.ARB, NSAIDs, metronidazole)

Question 14

What is Bipolar affective disorder Type II

Answer 14

Has HYPOmania and depression

Question 15

Sodium valproate started for the first time NICE guidelines?

Answer 15

Needs two specialists to prescribe those under 55

look out to safeguard women of reproducive age (can cause neural tube defect)

Question 16

If Lithium is not effective for long term BPAD management, next step?

Answer 16

Add sodium valproate (give both drugs together)

If lithium is poorly tolerated = valproate alone or olanzapine alone.

Question 17

What is rapid cycling Bipolar affective disorder?

Answer 17

More than 4 episodes per year

Question 18

What is cyclothymia?

Answer 18

Rapid cycling BPAD (more than 4 episode per year) but where depression and mania are not severe enough to be diagnosed at BPAD

Question 19

rating scale of bipolar disorder?

Answer 19

Young mania rating scale - this is not to be done in primary care as any sign of mania requires urgent referral to psychiatry for assessment

Question 20

Clinical features of mania + hypomania: acronym?

Answer 20

**DIG FAST
**
D - distractability
I - Indiscretion / irritability (increased libido/spending/eating)
G - grandiosity
F - Flight of ideas (gives away mania compared to schizo)
A - activity increase (hypaeractive)
S - sleep deficit
T - talkativeness , (pressured speech)

Question 21

What is Bipolar affective disorder?

Answer 21

At least 2 episodes of mood disturbance, with one being manic/hypomanic

Question 22

What differentiates hypomania from mania?

Answer 22

Symptoms must last for >4 days but does not dsitrupt social functioning

Has NO psychotic symptoms

Question 23

What are the various symptoms associated with Mania?
- core
- speech + thought
- biological

Answer 23

Core symptoms : Elevated mood + increased energy

Speech and thought: increased talkativeness, flight of dieas, inceeased self esteem

Biological symptoms: decreased need for sleep, reduced focus, impulsive behaviour, increased sexual drive

Question 24

What is the alternative to lithium for BPAD for long term management?

Answer 24

Sodium valproate

Question 25

What is the 1st line mood stabiliser for mania (long term management) ? When to prescribe it?

Answer 25

Lithium - prescribe 4 weeks after acute episode It has anti suicide effects

Question 26

What may be given first to manic patients for sedation?

Answer 26

Lorazepam - benzodiazepine

Question 27

How to treat severe lithoum toxicity above >3,5 mmol/L? how does it usually present

Answer 27

Haemodialysis Often presents with seizures

Question 28

What may precipiate manic symptoms? (medication)

Answer 28

SSRI

Question 29

Lithium toxicity often presents with a x tremor compared to a y tremor seen in therapuetic levels.

Answer 29

x - course y - fine

Question 30

Symptoms of mania presenting to GP?

Answer 30

Needs and URGENT referral to CMHT | NEEDs to be mania HYPOMANIA is a routine referral