Bipolar

Bipolar disorder

mental illness with cyclic fluctuations in mood (mania, hypomania, depression)

2 types

• 1 min 1 manic ± major depressive episode or hypomania

• 2 min 1 depressive episode + min 1 episode of hypomania + no hx of manic episode

Risk factors of Bipolar

substance abuse

family hx

psychosocial

head trauma

perinatal insult

Most common in

adolescents 15-30 yo (mean age 21y/o)

Mania

• no sleep

• more self-esteem

• mood disturbance has effect on social or occupational functioning

• symptoms present >= 1 week and present nearly every day or other condition

• faster speech

• racing thoughts, easily distracted

• goal directed activity or agitation

• not attributed to substance

Mania - DIG FAST

distractibility

impulsivity

grandiosity

flight of idea

activity increase

sleep deficit

talkative

hypomanic episode

• not severe enough for impairment in social/occupation function (no hospitalization)

• at least 4 consecutive days and most of day

Medical causes of Manic symptoms

CNS

Infection

Electrolyte or metabolic abnormality

Endocrine or hormonal dysregulation

Non-pharm for bipolar

• MANIA - d/c antidepressants, stimulants, nicotine, caffeine (at the start of diagnosis)

• DEPRESSION - d/c BZD (at the start of diagnosis)

• ECT (last resort)

• CBT

• Psychoeducation programs

mood stabilizers in bipolar disorder take how long for effect

2-4 weeks

Lithium

• 1st line for acute mania, maintenance, mild depression

• Monitor Li 12hr after dose every 2 months

  • acute

  • maintenance

  • elderly

acute mania Li level

0.8-1.2

maintenance Li level

0.6-1.0

Li toxicity is seen at

1.5

What increases lithium levels?

• dehydration

• large change in Na

• NSAIDs

• ACEI

What should be monitored with Li treatment?

• Renal

• thyroid function (can cause hyperparathyroidism→Hypercalcemia, hypothyroidism>hyperthyroidism)

AE of Li

• ataxia

• impaired neurocognition

• thyroid abnormality

Tremors on Li therapy - try these:

• decrease/eliminate caffeine

• Li dose reduction

• addition of beta blocker

• avoid in lactation

Valproic acid/DVPX

• Valproic level monitored during initation and titration

• teratogenic

Lamotrigine aspects

• all pt that develop a rash must stop lamotrigine and see ER asap → can turn into SJS or TENS

• wt neutral

• NAUSEA

Carbamazepine

• good for mixed states

• titrated slowly to avoid SJS and TENS

• most monitor to avoid toxicity (no correlation btwn serum level and efficacy)

First line monotherapy acute mania regimen in order (unless pt factors specify otherwise

1. Li

2. quetiapine

3. Vlproic Acid

4. Asenapine

5. Aripiprazole

6. Paliperidone

7. risperdone

8. cariprazine

1st line combination therapy acute mania

• Quetiapine + Li/DVP

• Aripiprazole + Li/DVP

• Risperidone + Li/DVP

• Asenapine Li/DVP

2nd line tx for acute mania

• olanzapine

• carbamazepine

• olanzapine +Li/DVP

• Li +DVP

• ziprasidone

• haloperidol

• ECT

1st line Acute depression bipolar (chose in order they are given)

• quetiapine

• lurasideone + Li/DVP

• Lamotrigne

• Lurasidone

• Adjunctive Lamotrigne

2nd line Acute depression bipolar (chose in order they are given)

• DVP

• adjunctive SSRI/Bupropion

• ECT

• Cariprazine

• olanzapine + fluoxetine

Maintenance of bipolar prevention of mood episode 1st line

• lithium

• quetiapine

• DVP

• lamotrigne

• asenapine

Maintenance of bipolar prevention of mood episode 1st line - PREVENTION OF DEPRESSION ONLY

• Aripiprazole + Li/DVP

• Aripiprazole PO

• Aripiprazole LAI

2nd line maintenance of mood episode

monitoring parameters

2-4 weeks - improved mood, thoughts, behaviour, sleep - use MDQ

1st line monotx for acute mania

1st line monotx for acute depression

1st monotx for maintenance tx

why are AP difficult in conception?

conventional antipsychotics and risperidone increase prolactin which interferres with ovulation and decrease fertility (may need d/c)

• taper prior to conception - must be stable for 4-6 months and low risk of relapse