Bipolar

Question 1

What is bipolar disorder?

Answer 1

cyclical mood disorder (mania, depression)

Question 2

What can induce bipolar disorder? (4)

Answer 2

• antidepressants, CNS stimulants -> induce mania (increase NA/DA transmission)
• drug withdrawal (alcohol, benzodiazepines, antidepressants, opioids, barbiturates)
• CNS disorders (strokes, head injuries)
• endocrine / hormonal dysregulation (thyroid, Cushing’s)

Question 3

Clinical presentation of mania?

Answer 3

DIGFAST

Distractibility & easily frustrated
Irresponsibility & erratic uninhibited behaviour
Grandiosity (inflated self-esteem)
Flight of ideas (racing thoughts)
Activity increase
Sleep less
Talkativeness

Question 4

Duration of sx for bipolar to be considered?
- major depressive sx
- manic sx
- hypomanic sx

Answer 4

• major depressive sx >2w (functional impairment)
• manic sx ≥1w (functional impairment)
• hypomanic sx ≥4D (no functional impairment or psychosis), eventually becomes manic

Question 5

Types of bipolar?

Answer 5

• Bipolar I: mania +- depressive episodes
• Bipolar II: hypomania + depressive episodes

Question 6

Nonpharm for bipolar?

Answer 6

• psychoeducation about disorder, tx & monitoring
• psychotherapy, interpersonal therapy, CBT
• stress reduction, relaxation therapy
• sleep hygiene
• nutrition
• exercise

Question 7

How fast do meds work for bipolar?

Answer 7

3-5D

Question 8

Treatment options for mania? (1st line and others)

Answer 8

1st line: lithium (maintenance & relapse/suicide prevention)

Others: antipsychotics (olanzapine, quetiapine, risperidone, aripiprazole, haloperidol), valproate, carbamazepine

Question 9

Treatment options for bipolar depression? (1st line & others)

Answer 9

1st line: lithium (maintenance & relapse/suicide prevention)

Others: antipsychotics (quetiapine, olanzapine + fluoxetine, lurasidone, cariprazine), lamotrigine

Question 10

Which drug used for bipolar depression does not have anti-manic properties, and which drug used for mania does not have antidepressant effects?

Answer 10

No anti-manic: lamotrigine
No antidepressant: haloperidol

Question 11

What role do benzodiazepines have in bipolar?

Answer 11

Help pt relax & sleep (short course, PRN)

Question 12

Main goals of therapy for bipolar?

Answer 12

• reduce frequency, severity & duration of mood episodes
• prevent suicide

Question 13

Side effects of lithium? (5)

Answer 13

• tremors, fatigue, cognitive impairment
• polyuria, diabetes insipidus
• hypothyroidism
• ECG changes
• N/V/D, weight gain

Question 14

Does lithium require TDM?

Answer 14

Yes

Question 15

Toxicity levels of lithium:
- mild
- moderate
- severe

Answer 15

• mild: 1.5-2.0
• moderate: 2.0-2.5
• severe: >3.0

Question 16

Side effects at different toxicity levels of lithium?
- mild (7)
- moderate (8)
- severe (7)

Answer 16

• mild: N/V, loose stools, lethargy, drowsy, lightheaded, confusion, coarse hand tremors
• moderate: severe N/V/D, ataxia, slurred speech, blurred vision, worsening confusion, profound lethargy, tinnitus, apathy
• severe: severe N/V/D, seriously impaired consciousness, increase deep tendon reflexes, stupor, coma, seizures, death

Question 17

Target lithium levels:
- acute mania
- maintenance

Answer 17

• acute mania: 0.8-1.0
• maintenance: 0.6-1.0

Question 18

DDI with lithium?

Answer 18

STAND (increase Li)
- sodium depletion
- thiazides
- ACEi/ARB
- NSAIDs
- dehydration
+ fluoxetine

+ neurotoxicity (with carbamazepine, phenytoin, non-DHP CCB, losartan, methyldopa, metronidazole)
+ caffeine & theophylline (increase renal elimination of Li)

Question 19

When to switch / add another drug for bipolar?

Answer 19

No response within 2-4w

Question 20

How is lithium eliminated?

Answer 20

Renal elimination