Bipolar Disorder (copy)

Bipolar I

at least one episode of mania

Bipolar I Mania Criteria

hyperactive episodes that lead to psychosis, delusions, hospitalizations

Bipolar II

at least one episode of hypomania

Bypolar II Hypomania Criteria

hyperactive episodes that do not affect social/work functioning and does not cause psychosis or require hospitalization

Bipolar disorder is characterized by:

fluctuations in mood from extremely helpless (depressive) --> elevated, overexcited, irritable (mania/hypomania)

each mood episode is drastically different from pt normal mood/behavior

Why is bipolar disorder often misdiagnosed?

If pt comes to clinic during depressive episode can be misdiagnosed as depression only

DSM-5 Mania/Hypomanmia: S/Sx and Dx

- inflated self-esteem

- needs less sleep

- more talkative than normal

- jumping from topic to topic

- easily distracted

- increased goal-directed activities

- high-risk, pleasurable activities

must exhibit at leas 3 of these symptoms or 4 if mood is only irritable

DSM-5 Mania/Hypomania: Definition

abnormally elevated or irritable mood for at least 1 week or any duration if hospitalization is needed

What is the goal of treatment?

stabilize the mood without inducing a depressive or manic state

What is the role of antipsychotics for bipolar disorder?

to help stabilize the mood when mania causes psychosis

What should antidepressants not be used as monotherapy?

they can induce or exacerbate a manic episode so they should only be used in combination with a mood stabilizer

What should be considered when choosing a drug tx for bipolar disorder?

SE profile, pt/pt family medication hx (can help with predicting response), formulations available, cost

What is used first line for acute tx of a manic episode?

anti-epileptic valproate or lithium

What is used first line for acute tx of a severe manic episode?

anti-epileptic valproate or lithium + antipsychotic

What is used for acute tx of depressive episode?

1. antipsychotic like quetiapine or lurasidone

2. epileptic like lithium, valproate, or lamotrigine

What anti epileptic drugs can be used for bipolar disorder?

valproate, lamotrigine, carbamazepine

Describe maintenance tx for bipolar disorder

continue the meds that were effective for the acute episode to prevent relapse (ex: lithium or anti epileptic)

What is recommended for all patients receiving antidepressants or antipsychotics for bipolar disorder?

MedGuides

- antidepressants due to increased risk suicide

- antipsychotics due to increased risk death in pt with dementia-related psychosis

What is the safest option for pregnant patients with bipolar disorder?

- lamotrigine

- lurasidone: favorable safety profile but only FDA approved for bipolar depression

What medications should not be used in pregnant women and why?

- valproate: cognitive defects

- carbamazepine: facial anomolies

- lithium: cardiac malformations

Why does lamotrigine require a slow taper?

risk of severe rash

What is the brand name for lamotrigine?

Lamictal

What is the brand name for valproate?

Depakote

What antipsychotics are used for bipolar disorder?q

2nd generations:

- aripiprazole

- olanzapine

- quetiapine

- risperidone

- ziprasidone

- lurasidone

What is the brand name for aripirazole?

Abilify

What is the brand name for olanzapine?

Zyprexa

What is the brand name for quetiapine?

Seroquel

What is the brand name for risperidone?

Risperdal

What is the brand name for ziprasidone?

Geodon

What is the brand name for lurasidone?

Latuda

What its the brand name for lithium?

Lithobid

Lithium: Warnings

serotonin syndrome

Lithium: SEs

GI upset, cognitive effects, cogwheel rigidity, tremor, thirst, polyuria/polydipsia, weight gain, hypothyroidism

Lithium Toxicity

if levels > 1.5: ataxia coarse hand tremor, vomiting

if levels > 2.5: CNS depression, arrhythmia, seizure, coma

Lithium therapeutic range

0.6-1.2 mEq/L trough

Lithium: Monitoring

lithium levels, renal function, thyroid function

Is lithium renal cleared?

yes

Drug Interactions: What increases lithium levels?

- ACEi, ARBS: low salt intake/Na loss

- NSAIDS

Drug Interactions: What decreases lithium levels?

- increased salt intake

Lithium: Drug Interactions

avoid with meds that increase risk of serotonin syndrome: SSRIs, SNRIs, triptans, linezolid, etc.

Lithium Conversions: citrate syrup --> ions --> lithium carbonate

5 mL Li citrate syrup = 8 mEq of Li ions = 300 mg Li carbonate