psych - bipolar disorder

Fluctuations in mood from extremely sad or hopeless state to an abnormally elevated, overexcited or irritable mood called mania or hypomania.

Bipolar Disorder

Bipolar I or Bipolar II

At least one episode of mania and bouts of intense depression

Bipolar I

Bipolar I or Bipolar II

At least one episode of hypomania (lasting > 4 consecutive days) and at least one depressive episode (lasting > 2 weeks)

Bipolar II

_____ is associated with at least one of the following

1. Significant impairment in social/work functioning

2. Psychosis/Delusions

3. Requires hospitalization

Mania

________ does not do the following:

1. Affect social/work function

2. Cause psychosis

3. Require hospitalization

Hypomania

Stabilize the mood without inducing a depressive or manic state

Goals of bipolar treatment

Which medications can be used to treat both mania and depression without inducing either state?

Lithium and ASMs

Which ASMs can be used in bipolar treatment?

Valproate, Lamotrigine, Carbamazepine

Traditional mood stabilizer used in bipolar disorder

Lithium

What other medications can be used in bipolar disorder treatment?

Antipsychotics, antidepressants

Which medications can induce or exacerbate manic episodes when used alone and should only be used with a mood stabilizer?

Antidepressants

Which medications can stabilize the mood when mania occurs with psychosis?

Antipsychotics

First-line treatment for acute manic episodes

Antipsychotics, Lithium or Valproate

First-line treatment for severe acute manic episodes

Antipsychotic + Lithium or Valproate

First-line treatment for acute depressive episodes

Antipsychotics

Which antipsychotics are first line for acute depressive episodes?

Quetiapine, Lurasidone, Symbyax

Alternative medications that can be added or used as an alternative in a depressive episode

Lithium, valproate, lamotrigine

Latuda

Lurasidone

Latuda is only used for which bipolar episode?

Depressive episodes

Symbyax is only used for which bipolar episode?

Alone for acute depressive episodes

MOA: Influences the reuptake of serotonin and/or norepinephrine or by moderating glutamate levels in the brain.

Lithium

Lithobid

Lithium

Lithium counseling

Take with food and drink lots of water

Lithium therapeutic range

0.6-1.2 mEq/L (trough)

Acute mania may require a lithium trough level up to what?

1.5 mEq/L

Signs of Lithium toxicity > 1.5 mEq/L

Ataxis, coarse hand tremor, vomiting

Signs of Lithium toxicity > 2.5 mEq/L

CNS depression, arrhythmia, seizure, coma

Lithium monitoring

Lithium levels, renal function, thyroid function (TSH, FT4), electrolytes

- GI upset

- Cognitive effects

- Cogwheel rigidity

- Tremor

- Thirst

- Polyuria/polydipsia

- Weight gain

- Hypothyroidism

Lithium side effects within therapeutic range

• Renal impairment

• Hyponatremia

• Dehydration

• Serotonin syndrome

Lithium warnings

What can cause high lithium levels?

Low salt intake, NSAIDs

What can cause low lithium levels

High salt intake, caffeine, theophylline

Lithium has an increased risk of neurotoxicity if taken with which medications?

Non-DHP CCBs, phenytoin, carbamazepine

Lithium dosage formulation conversions

5 mL lithium citrate syrup = 8 mEq of lithium ion = 300 mg lithium carbonate

Lithium starting dose

300-900 mg/day divided BID-TID (MDD: 900-1800 mg/day divided BID-TID)

Medications that CANNOT BE USED in pregnancy

Valproate, Carbamazepine, Lithium

Medications that CAN BE USED in pregnancy

Lamotrigine, Lurasidone