10- Bipolar Disorder: Treatment

Source: https://app.lecturio.com/#/lecture/c/7526/59632/33050

Correct answer: C. Resolution of mood symptoms or persistence of only 1–2 mild symptoms

Explanation:
Remission in bipolar disorder means resolution of mood symptoms or improvement to the point that only one or two mild symptoms remain. Bipolar disorder is chronic, so complete cure is unrealistic.

• A is incorrect (bipolar disorder is lifelong).

• D describes response, not remission.

Treatment Goals in Bipolar Disorder

Which of the following BEST defines remission in bipolar disorder?

A. Complete and permanent disappearance of bipolar disorder
B. Absence of all mood symptoms for at least 5 years
C. Resolution of mood symptoms or persistence of only 1–2 mild symptoms
D. Stabilization of safety without improvement in mood symptoms

Correct answer: B. Treat psychosis and safety concerns first

Explanation (clarified):
Psychotic symptoms (delusions, hallucinations) are most dangerous and must be addressed first.

✔ Clarification: Antipsychotics often treat both psychosis and mood symptoms simultaneously, so treatment is not delayed—safety is prioritized.

Priority of Treatment When Psychosis Is Present

In a patient with bipolar disorder and active psychotic symptoms, what is the initial treatment priority?

A. Treat depressive symptoms first
B. Treat psychosis and safety concerns first
C. Begin psychotherapy immediately
D. Delay treatment until mood symptoms stabilize

Correct answer: C. Response to treatment

Explanation:
Response is defined as stabilization of safety and substantial improvement in number, intensity, and frequency of symptoms, even if remission is not achieved.

Response vs Remission

A patient does not reach remission but becomes safer with fewer and less intense mood symptoms. This outcome is best described as:

A. Relapse
B. Partial remission
C. Response to treatment
D. Treatment resistance

Correct answer: C. Active suicidal ideation requiring close monitoring

Explanation:
Inpatient care is required when safety cannot be ensured, especially with active suicidal ideation.

Indications for Inpatient Hospitalization

Which situation MOST strongly indicates inpatient hospitalization for bipolar disorder?

A. Stable mood with good social support
B. Passive suicidal thoughts without intent
C. Active suicidal ideation requiring close monitoring
D. Mild hypomania without impairment

Correct answer: C. It is excreted by the kidneys

Explanation:
Lithium is renally excreted, not metabolized by the liver, and has a narrow therapeutic index, making toxicity clinically significant.

Lithium Pharmacokinetics

Which statement about lithium is CORRECT?

A. It is metabolized in the liver
B. It has a wide therapeutic window
C. It is excreted by the kidneys
D. Toxicity is rare and mild

Correct answer: B. NSAIDs

Explanation (correction):

• NSAIDs increase lithium levels by reducing renal clearance.

• ❌ Theophylline actually DECREASES lithium levels (important correction).

Lithium Drug Interactions (Correction Included)

Which medication is MOST likely to increase lithium levels and cause toxicity?

A. Theophylline
B. NSAIDs
C. Caffeine
D. Osmotic laxatives

Correct answer: C. Nystagmus and delirium

Explanation:
Severe toxicity causes neurologic symptoms such as nystagmus, delirium, seizures, coma, and arrhythmias.

• A, B, and D are common non-toxic side effects.

Lithium Toxicity Presentation

Which of the following symptoms suggests severe lithium toxicity?

A. Metallic taste
B. Mild tremor
C. Nystagmus and delirium
D. Weight gain

Correct answer: C. Hemodialysis

Explanation:
Lithium level >3 mmol/L or severe neurologic symptoms → hemodialysis to prevent renal and systemic damage.

Management of Severe Lithium Toxicity

A patient has a lithium level of 3.2 mmol/L with neurologic symptoms. Best management?

A. Oral hydration only
B. Stop lithium and observe
C. Hemodialysis
D. Activated charcoal

Correct answer: C. Ebstein anomaly

Explanation:
Lithium is associated with Ebstein anomaly, a congenital cardiac defect.

Teratogenic Effects of Mood Stabilizers

Which fetal anomaly is associated with lithium exposure during pregnancy?

A. Spina bifida
B. Neural tube defect
C. Ebstein anomaly
D. Cleft palate

Correct answer: B. Spina bifida

Explanation:
Both drugs increase the risk of neural tube defects, especially spina bifida.

Valproate and Carbamazepine in Pregnancy

Which fetal abnormality is most strongly associated with valproic acid and carbamazepine?

A. Ebstein anomaly
B. Spina bifida
C. Ventricular septal defect
D. Limb reduction defects

Correct answer: C. Quetiapine (Seroquel)

Explanation:
Quetiapine is an atypical antipsychotic.
Haloperidol, chlorpromazine, and fluphenazine are typical agents.

Antipsychotic Classification

Which of the following is an atypical (second-generation) antipsychotic?

A. Haloperidol (Haldol)
B. Chlorpromazine (Thoradol, Thorazine)
C. Quetiapine (Seroquel)
D. Fluphenazine (Prolixin, Permitil)

Correct answer: C. Strong dopamine D2 antagonism

Explanation (clarified):
EPS are caused by strong D2 receptor blockade, classically seen with high-potency typical antipsychotics.

✔ Potency is not the same as typical vs atypical, but correlates with D2 affinity.

Dopamine Blockade and Side Effects (Clarification)

Which antipsychotic property is MOST associated with extrapyramidal side effects (EPS)?

A. Serotonin receptor antagonism
B. Histamine receptor blockade
C. Strong dopamine D2 antagonism
D. Muscarinic receptor blockade

Correct answer: C. Flat affect

Explanation:
Negative symptoms include flat affect, avolition, alogia, social withdrawal, and psychomotor retardation.

Negative Symptoms of Psychosis

Which of the following is a negative symptom?

A. Auditory hallucinations
B. Delusions of grandeur
C. Flat affect
D. Pressured speech

Correct answer: C. They are highly addictive

Explanation:
Benzodiazepines (e.g., lorazepam) act quickly and help acute mania but carry high addiction potential, especially in patients with comorbid substance use.

Benzodiazepines in Bipolar Disorder

Why should benzodiazepines be used cautiously in bipolar disorder?

A. They worsen depression
B. They are ineffective in mania
C. They are highly addictive
D. They cause extrapyramidal symptoms

Correct answer: B. Bipolar disorder in pregnancy refractory to medication

Explanation:
ECT is highly effective, rapid, and safe in pregnancy, especially when medications are contraindicated.

ECT in Bipolar Disorder

Which scenario is a strong indication for ECT?

A. Mild hypomania
B. Bipolar disorder in pregnancy refractory to medication
C. Stable bipolar disorder on lithium
D. First episode of mild depression

Correct answer: C. Irritability

Explanation:
Irritability is a hallmark of mixed episodes and is an important diagnostic clue.

Mixed Episodes – Clinical Pearl

What is the predominant mood state in a mixed episode of bipolar disorder?

A. Euphoria
B. Anxiety
C. Irritability
D. Apathy

Correct answer: B. Most effective for bipolar depression and maintenance

Explanation:
Lamotrigine is not effective for acute mania. Its main role is bipolar depression and long-term maintenance.

Lamotrigine – Role in Bipolar Disorder

Which statement BEST describes lamotrigine in bipolar disorder?

A. First-line treatment for acute mania
B. Most effective for bipolar depression and maintenance
C. Used only when lithium fails in acute psychosis
D. Contraindicated in bipolar disorder

Correct answer: B. Stevens–Johnson syndrome

Explanation:
Lamotrigine (Lamictal) carries a risk of Stevens–Johnson syndrome, especially if titrated too quickly. Slow dose escalation is critical.

Lamotrigine – Serious Adverse Effect

Which potentially life-threatening adverse effect must be monitored when starting lamotrigine (Lamictal)?

A. Agranulocytosis
B. Stevens–Johnson syndrome
C. Neuroleptic malignant syndrome
D. Torsades de pointes

Correct answer: B. Renal function and thyroid function tests

Explanation:
Lithium affects:

• Kidneys → monitor creatinine/BMP

• Thyroid → risk of hypothyroidism

Baseline and periodic monitoring are mandatory.

Lithium Monitoring (Uncovered Detail)

Before starting lithium therapy, which baseline investigations are MOST important?

A. Liver function tests and coagulation profile
B. Renal function and thyroid function tests
C. ECG only
D. Lipid panel and HbA1c

Correct answer: B. Hypothyroidism

Explanation:
Lithium (Eskalith) can impair thyroid function, commonly causing hypothyroidism, even without overt symptoms.

Long-Term Lithium Adverse Effect

Which condition may develop during chronic lithium therapy and requires routine screening?

A. Hyperthyroidism
B. Hypothyroidism
C. Addison disease
D. Cushing syndrome

Correct answer: D. Outpatient care

Explanation:
Although hospitalization is crucial for safety, most bipolar patients are treated as outpatients, provided they are stable and not a danger to themselves or others.

Most Common Treatment Setting for Bipolar Disorder

Most patients with bipolar disorder are treated in which setting?

A. Inpatient psychiatric units
B. Partial hospitalization programs
C. Emergency departments
D. Outpatient care

Correct answer: C. Patient with suicidal thoughts but no intent or plan

Explanation:
Partial hospitalization is appropriate for moderately ill patients who:

• Have suicidal thoughts

• Feel safe

• Have no intent or plan

They receive daytime intensive treatment and return home at night.

Partial Hospitalization – Key Feature

Which patient is MOST appropriate for partial hospitalization?

A. Actively suicidal with a plan
B. Stable patient with no suicidal thoughts
C. Patient with suicidal thoughts but no intent or plan
D. Patient in acute psychotic mania

Correct answer: C. Metabolic syndrome

Explanation:
Atypical antipsychotics increase risk of:

• Weight gain

• Diabetes

• Dyslipidemia

EPS (A, B, D) are more common with typical antipsychotics.

Metabolic Effects of Atypical Antipsychotics

Which adverse effect is MOST associated with atypical antipsychotics?

A. Acute dystonia
B. Tardive dyskinesia
C. Metabolic syndrome
D. Oculogyric crisis

Correct answer: C. They are more responsive to atypical antipsychotics

Explanation:
Negative symptoms are:

• Core in schizophrenia

• More responsive to atypical antipsychotics

• Often persistent and difficult to treat

Negative Symptoms – Clarification Applied

Which statement about negative symptoms is MOST accurate?

A. They respond best to typical antipsychotics
B. They are the defining feature of all psychotic disorders
C. They are more responsive to atypical antipsychotics
D. They are usually transient