Bipolar Disorder

  1. what is type 1 bipolar
    cycles of major depression, mania not at the same time
  2. what is type II bipolar disorder
    major depression alternating with hypomania
  3. definition/frequency of mixed episodes
    both Major depression and manic episodes everyday for at least 1 week
  4. manic episodes may be precipitated by
    • stress
    • sleep deprivation
    • antidepressants
    • cns stimulants
    • bright light
  5. diagnosis of hypomanic episdoe
    at least 4 DAYS of abnormal and persistent elevated mood (expansive or irritable)
  6. diagnosis of manic episodes
    at least ONE WEEK period of abnormal and persistent elevated mood
  7. difference between hypomanic episodes from manic episode
    • in hypomanic episode there is:
    • -no hallucinations
    • -no delusions
    • -less severe mania
    • -no marked impairment (cant function prop)
    • -more preductive/creative than usual
  8. what is rapid cycling
    4 or more separate episodes of depression, mania, hypomania, or mixed episodes within 1 year
  9. medications that induce mania
    • antidepressants
    • corticosteroids
    • cns stimulants
    • theophylinne
    • thyroid preparations
    • caffeine
    • st johns wort
    • alcohol toxication
    • drug withdrawal
    • pseudoephedrine
    • marijuana intoxication
    • hallucinogens (lsd)
  10. treatment goals
    • complete remission
    • prevent relapses
    • return to psychosocial funtioning
    • maximize medication adherence
    • eliminate substance abuse
    • avoid stressors that precipitate episodes eliminate suicide attempts
  11. what is complete remission
    no sx, normal function between episodes
  12. guidelines for treating bipolar disorder
    • -american psychiatric assoc. (APA)
    • -expert consensus series
    • -texas medication algorithm project
    • -veterans affairs/Department of defense guidelines
  13. what are some non pharmacological therapies
    • psychotherapy
    • stress reduction (yoga, massage)
    • good sleep hygiene
    • proper nutrition intake
    • regular exercise
  14. which drug is preferred over lithium to treat mixed episodes and rapid cycling
  15. what is first line for bipolar depression
  16. what are lithium and divalproex first line agents for
    monotherapy in acute and maintanence treatment
  17. therapeutic ranges of Li
    0.8-1.2 mEq/L
  18. serum trough concentrations of valproate should be
    50-125 mcg/ml
  19. the serum trough concentration of carbamazepine should be maintained between
    4-12 mcg/ml
  20. what do we do to serum concentrations (therapeutic ranges for Li, valproate, carbamazepine) if pt has partial response or breakthrough occurs
    adjust dose to higher concentrations
  21. antidepressant monotherapy is not recommended
    bipolar depression
  22. what are advantages of treating a pt with a combo drug
    combo drugs may provide a better acute response and prevention of relapse
  23. which cases are combo drugs especially useful in
    mixed episodes and rapid cyclers
  24. what is a treatment resistant case and how do you treat it
    treatment resistance is defined as refractory to Li + anticonvulsant; must add an antipsychotic
  25. what do we add to treat a pt with agitation
    BZD (watch for substance abuse)
  26. Li brand names and doses
    • eskalith         300
    • eskalith CR     450
    • lithobid          300
    • Li (generic)     150, 300, 600
  27. initial dosing ranges of Li
    600-900mg/day in divided doses
  28. Li maintenance dose range
    900-2400 mg/day in div doses
  29. counseling points with Li
    • -it is a mood stabilizer (help stable moods)
    • -can take w/ or w/out food (food preffered)
    • -may experience GI (NVD), fatigue, wt gain,
    • -store at room temp
  30. how long does it take to see the full effects of lithium to treat mania
    1-2 weeks (may use APs and/or BZD as adjunctive therapy during this period for agitation and other symptoms)
  31. how long does it take to see antidepressant effects of lithium
    may take 6-8 wks
  32. manage lithium ADEs
    • -rash= d/c temp or permanently
    • -tremor= reduce dose; add b-blocker (inderal)
    • -cns toxicity= reduce dose
    • -GI (NVD)= reduce dose; try extended release product
    • -hypothyroidism= DC lithium or give levoxyl
    • -polydypsia/polyuria= reduce dose; HS dosing; try amiloride or hctz (hctz could increase concentration of lithium)
    • -interstitial fibrosis= keep at lowest effective concentration
    • -teratogenicity= do not give in first trimester
  33. other Li ADEs
    • fatigue 
    • wt gain
    • folliculitis
    • neutropenia
    • acne
  34. rare Li SEs
    • renal toxicity
    • hypercalcemia
    • ECG changes
  35. Pre-lithium work ups
    • complete cbc (bc of neutropenia)
    • urinalysis
    • thyroid function
    • renal function
    • EKG
    • electrolytes
    • pregnancy test
  36. how often do you repeat lithium lab tests
    6-12 months
  37. Lithium drug interactions
    • Thiazides= increase Li conc
    • NSAIDS= increase Li conc
    • Theophylline= decrease Li conc
    • ACEIs= increase Li conc
    • Neuromuscular blockers= Li prolong NM action
    • Neuroleptics= Li may potentiate EPS
    • Carbamazepine= increase CNS toxicity
    • Thyroid= decrease Li synthesis and release of TH; leads to hypothyroidism
  38. most commonly prescribed mood stabilizer in the US
    • Divalproex
    • Valproate
    • Valproic acid
  39. divalproex/valporoate/valproic acid are as effective as lithium in;
    acute and prophylactic management
  40. brand names/dosing strengths for divalproex
    • depakote (DR) 125, 250, 500
    • depakote (sprinkle capsule) 125
    • depakote (ER) 250, 500
    • depakene 250
    • depakene 250mg/ml
  41. dosing range for valproic acid
    750-3000mg/day (20-60 mg/kg/day)
  42. valproic acid ADEs
    • nausea/anorexia
    • wt gain
    • sedation
    • tremor
    • rash 
    • alopecia
    • inhibits metabolism of other drugs
    • pancreatitis
    • hepatotoxicity
    • SJS
  43. lamotrigine brand name/dose strengths
    lamictal 25, 100, 150, 200mg (2, 5, 25mg chewable tablet)
  44. lamictal usual dose
  45. lamictal target dose
  46. how can lamotrigine be used
    as monotherapy or add on therapy for refractory bipolar depression
  47. common ADEs of lamictal
    • HA
    • nausea
    • dizziness
    • tremor
    • rash
    • pruritis
  48. carbamazepine brand names/dosing strength
    • -tegretol 200mg; chewable 100mg; sus 100mg/5ml
    • -tegretol XR 100, 200, 400mg
    • -carbatrol ER 200, 300 (capsule may be sprinkled over food)
    • -equetro ER 100, 200, 300
  49. Oxcarbazine brand name/dose strengths
    trileptal 150, 300, 600mg; sus 300mg/5ml
  50. which drugs are not approved for bipolar disorder
    carbamazine, oxcarbazine
  51. carbamazine, oxcarbazepine usually reserved for what type of pts
    lithium-refractory pts, rapid cyclers or mixed states
  52. Carb/Oxcarb dosing ranges
    • 200-1800mg (2-4 div doses)
    • 300-1200mg (2 div doses)
  53. women on OC taking oxcarbazepine or carbamazepine should do what
    take higher doses of oral contraceptives
  54. drug interactions that increase carbamazepine concentrations
    • cimetidine
    • diltiazem
    • erythromycin
    • fluoxetine
    • fluvoxamine
    • isoniazid
    • itraconazole
    • ketoconazole
    • verapamil
  55. oxcarbazepine compared to carbamazepine
    fewer ADEs and is better tolerated than carbamazepine
  56. FDA approved for the treatment of acute mania in bipolar disorder:
    • aripiprazole (abilify)
    • olanzapine (zyprexa)
    • quetiapine (seroquel)
    • risperidone (risperdal, consta)
    • ziprazidone (geodon)
  57. only FDA approved option for bipolar depression
  58. AAP approved for maintenance treatment of bipolar disorder
  59. what can clozapine be used for in the treatment of bipolar disorder
    refractory bipolar disorder
  60. use of BZDs
    for acute mania, agitation, anxiety, panic, insomnia, pts who cannot take mood stabilizers
  61. drug used for acute agitation
    lorazepam (ativan)
  62. BZD contraindication
    pts with substance abuse
  63. antidepressant added for:
    the treatment of acute depression (can be added on)
  64. TCAs and SNRIs are associated with:
    an increased risk for inducing mania and rapid cycling
  65. when should antidepressants be withdrawn
    2-6 mnths
  66. valproate has a risk of what in the first trimester
    neural tube defect
Card Set
Bipolar Disorder
Bipolar treatment guidelines