Mood Stabilizers

Question 1

Biogenic Amine Hypothesis
Chronobiologic Theories
Sensitization and Kindling theory
Genetic Factors

Answer 1

Theories of Mood Disorders (Bipolar Disorder)

Question 2

Monoamine – neurotransmitters for depression & mania (specific)

Answer 2

Biogenic Amine Hypothesis

Question 3

Circadian rhythm related

Answer 3

Chronobiologic Theories

Question 4

Electrical storm of sensitization in the brain & kindling – more action potential stuff happening, brain is ready to have rapid firing (kindled and ready to go) – affects all parts of the brain (hypothalamus is controlled by where mood and kindling is controlled). This is why antiseizure medications are used to treat bipolar disorder – this theory is why

Answer 4

Sensitization and Kindling theory

Question 5

Strong likelihood of genetic factors – if family members have schizophrenia, higher risk of bipolar

Answer 5

Genetic Factors

Question 6

Anti-Mania medications (mood stabilizer medications)
Anticonvulsant medication
Antipsychotic medication

Answer 6

Treatment of Bipolar Disorders

Question 7

______ is anti-mania medication

Answer 7

Lithium

Question 8

Generally used short term, acute episodes vs long term maintenance use

Answer 8

Antipsychotic medication

Question 9

Anti-mania

Answer 9

lithium carbonate (Carbolith)

Question 10

Used to be used as a table salt – ________ toxicity
Has relationship w sodium

Answer 10

lithium

Question 11

Modify nerve cell function
Also thought to increase the level of inhibitory neurotransmitter GABA (Gamma- aminobutyric acid)

Answer 11

Anticonvulsants - Drugs that Suppress Sodium Influx

Question 12

Decrease dopamine levels when a person is experiencing mania
Often used in combination with other mood stabilizers

Answer 12

Antipsychotics

Question 13

May be administered concurrently with mood stabilizers to treat Acute Bipolar I Disorder with Depressive Symptoms AND Acute Bipolar II Disorder with Depressive Symptoms

Need to be administered with the mood stabilizer
medications to prevent rapid cycling from depression to mania

Answer 13

Antidepressants

Question 14

ANTIDEPRESSANTS USED AS _________ FOR MOOD STABILIZATION:

Selective Serotonin Reuptake Inhibitors
Selective Serotonin and Norepinephrine Reuptake Inhibitors
Atypical Antidepressants (bupropion, mirtazapine, trazadone & moclobemide)

Answer 14

ADJUNCTS

Question 15

Antidepressants used with caution – More common with Acute ___________

More common with bipolar II because more depressive symptoms – not fully mania
Should be administered concurrently w a mood stabilizer

Answer 15

Bipolar II

Question 16

ABSORPTION
GI Tract
DISTRIBUTION
Same as water **
Crosses the blood brain barrier slowly
Widely distributed through the body
METABOLISM
Liver
EXCRETION
Kidneys
Usually 80% of filtered Lithium is reabsorbed **
Cross placenta and enter breast milk

Answer 16

Lithium

Question 17

Does not bind to serum proteins – nonprotein binding
Long term use can be very disruptive to the kidneys. Toxicity WILL damage the kidneys – there is a cumulative effect with each time they get into toxicity.

Answer 17

Lithium

Question 18

Low salt intake, dehydrated, low sodium concentration in the blood – then MORE than the 80% of _____ will be reabsorbed. Increases levels and increased levels of toxicity.

Answer 18

Lithium

Question 19

Acute: 900- 2400 mg
Maintenance: 400 – 1200mg

Answer 19

Lithium carbonate

Question 20

Lithium
Valproic acid/Divalproex (Epival)
Paliperidone (Invega)
Risperidone (Risperdal)
Quetiapine (Seroquel)
Aripiprazole (Abilify)
Asenapine (Saphris)

Answer 20

1st Line Acute Mania Treatment Options

Question 21

Lithium
Valproic acid/Divalproex
Carbamazepine (Tegretol)
Lamotrigine (Lamictal)
Quetiapine + Lithium or Divalproex
Aripiprazole + Lithium or Divalproex
Aripiprazole

Answer 21

1st Line Maintenance Treatment Options

Question 22

Serum Drug Levels are required with LiCO3
Baseline bloodwork:
- Renal
- Cardiac
- Thyroid
- Electrolytes

Answer 22

Lithium Carbonate (LiCO3)

Question 23

Upon initiation of LiCO3 - blood levels are required q 2- 3 days
Maintenance: every couple of months (if stable)
Lithium blood levels are best done 8 to 12 hours after the last dose
Acute Therapeutic Range is 0.6 – 1.2 mEq/L (mmol/L)
Maintenance Therapeutic Range 0.6-1.0mEq/L

Answer 23

Lithium Carbonate (LiCO3)

Question 24

Lithium and ________ are monovalent positive ions

Sodium levels need to be taken on a regular basis
Sodium levels should remain normal (135-145 mmol/L)
Patients should be advised to maintain a normal salt intake and to avoid over-hydration or dehydration

Answer 24

Sodium

Question 25

decreases lithium level

Answer 25

Overhydration

Question 26

increases lithium level

Answer 26

Dehydration

Question 27

Abdominal pain Tremor of hands Fatigue GI upset Vertigo Weight gain Thyroid abnormalities ECG changes Dermatological changes

Answer 27

<1.0 Lithium blood level

Question 28

Polyuria Increased drowsiness Blurred vision Muscular weakness Tremors Diarrhea Vomiting

Answer 28

1.0-2.0 Lithium blood level

Question 29

Confusion/disorientation Delirium Seizures Nystagmus Kidney failure Tachycardia Coma/death

Answer 29

>2.0 Lithium blood level

Question 30

Lithium toxicity ______ mEq/L (mmol/L)+

Answer 30

1.2-1.5

Question 31

Toxicity Manifestations Include: GI discomfort, tremor, confusion, fatigue, seizures and possibly death

Answer 31

Lithium Toxicity

Question 32

Treatment: Immediately notify the prescriber Withhold Lithium Obtain a Blood Sample to measure the lithium, sodium, and kidney function Emergency medical treatment Assess for neurological damage IV hydration

Answer 32

Lithium Toxicity

Question 33

Brain Damage Conditions requiring reduced sodium intake Renal Impairment Cardiac Impairment

Answer 33

Lithium contraindications

Question 34

NSAIDS Thyroid Conditions Psoriasis Hypercalcemia Diabetes Parkinson’s Disease Surgery – surgeon needs to be notified that the client is on Lithium Cannabis

Answer 34

Lithium precautions

Question 35

Lithium Toxicity Risk: Increases with _______ depletion and needs to be carefully monitored (vomiting, diarrhea, use of diuretics, heavy sweating etc.)

Answer 35

sodium

Question 36

Alcohol/ diuretics INCREASED dehydration/ fluctuating sodium levels SSRI INCREASED Risk of serotonin syndrome Carbamazepine/phenytoin INCREASED Risk of CNS toxicity Haldol INCREASED encephalopathy syndrome Phenothiazines (Typical Antipsychotics) INCREASED Risk for altered response from either drugs

Answer 36

Lithium Carbonate Interactions

Question 37

Lithium and Haldol – contraindicated/great caution – increased risk of ____________

Answer 37

encephalopathy

Question 38

___________ – increase dehydration / fluctuating sodium levels

Answer 38

Alcohol/diuretics

Question 39

_________ – increase risk encephalopathy syndrome. Encephalopathy is a group of conditions that cause brain dysfunction. Brain dysfunction can appear as confusion, memory loss, personality changes and/or coma in the most severe form. - vision changes, headache, weakness, tremors, lethargy, shutting down and sleeping.

Answer 39

Haldol

Question 40

__________ used in an acute episode – rapid tranquilization & increase safety of the person experience & and also the care provider - mixed features of irritability can occur w mania - not all sunshine and rainbows - people may do impulsive things (try to fly) – risk of death, when people try to stop you and bipolar people can become hostile quickly

Answer 40

Haldol

Question 41

Blood levels (renal intake and output & function, cardiac, electrolytes, thyroid) therapeutic effect at lowest dose (trough). Serum lithium levels – tolerable range and not in toxicity. Serum lipid levels (weight gain), waist circumference. Blood pressure (orthostatic hypotension). Hydration is important because dehydration increases level of lithium in their body, increase in toxicity. Knowing about exercise and interests i.e., hot yoga. Lithium toxicity signs. Earlier signs (aside from seizure). Any hint of lithium toxicity - so we can prevent irreparable damage.

Answer 41

Client teaching for Lithium

Question 42

Lithium Carbonate *Caution with clients with critical illness, renal, hepatic impairment  - lower doses will be necessary *Lithium level 0.4 to 0.6 in older adults

Answer 42

Older adult lithium considerations