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what is type 1 bipolar
cycles of major depression, mania not at the same time
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what is type II bipolar disorder
major depression alternating with hypomania
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definition/frequency of mixed episodes
both Major depression and manic episodes everyday for at least 1 week
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manic episodes may be precipitated by
- stress
- sleep deprivation
- antidepressants
- cns stimulants
- bright light
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diagnosis of hypomanic episdoe
at least 4 DAYS of abnormal and persistent elevated mood (expansive or irritable)
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diagnosis of manic episodes
at least ONE WEEK period of abnormal and persistent elevated mood
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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
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what is rapid cycling
4 or more separate episodes of depression, mania, hypomania, or mixed episodes within 1 year
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medications that induce mania
- antidepressants
- corticosteroids
- cns stimulants
- theophylinne
- thyroid preparations
- caffeine
- st johns wort
- alcohol toxication
- drug withdrawal
- pseudoephedrine
- marijuana intoxication
- hallucinogens (lsd)
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treatment goals
- complete remission
- prevent relapses
- return to psychosocial funtioning
- maximize medication adherence
- eliminate substance abuse
- avoid stressors that precipitate episodes eliminate suicide attempts
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what is complete remission
no sx, normal function between episodes
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guidelines for treating bipolar disorder
- -american psychiatric assoc. (APA)
- -expert consensus series
- -texas medication algorithm project
- -veterans affairs/Department of defense guidelines
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what are some non pharmacological therapies
- psychotherapy
- stress reduction (yoga, massage)
- good sleep hygiene
- proper nutrition intake
- regular exercise
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which drug is preferred over lithium to treat mixed episodes and rapid cycling
divalproex
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what is first line for bipolar depression
lamotrigine
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what are lithium and divalproex first line agents for
monotherapy in acute and maintanence treatment
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therapeutic ranges of Li
0.8-1.2 mEq/L
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serum trough concentrations of valproate should be
50-125 mcg/ml
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the serum trough concentration of carbamazepine should be maintained between
4-12 mcg/ml
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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
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antidepressant monotherapy is not recommended
bipolar depression
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what are advantages of treating a pt with a combo drug
combo drugs may provide a better acute response and prevention of relapse
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which cases are combo drugs especially useful in
mixed episodes and rapid cyclers
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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
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what do we add to treat a pt with agitation
BZD (watch for substance abuse)
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Li brand names and doses
- eskalith 300
- eskalith CR 450
- lithobid 300
- Li (generic) 150, 300, 600
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initial dosing ranges of Li
600-900mg/day in divided doses
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Li maintenance dose range
900-2400 mg/day in div doses
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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
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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)
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how long does it take to see antidepressant effects of lithium
may take 6-8 wks
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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
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other Li ADEs
- fatigue
- wt gain
- folliculitis
- neutropenia
- acne
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rare Li SEs
- renal toxicity
- hypercalcemia
- ECG changes
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Pre-lithium work ups
- complete cbc (bc of neutropenia)
- urinalysis
- thyroid function
- renal function
- EKG
- electrolytes
- pregnancy test
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how often do you repeat lithium lab tests
6-12 months
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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
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most commonly prescribed mood stabilizer in the US
- Divalproex
- Valproate
- Valproic acid
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divalproex/valporoate/valproic acid are as effective as lithium in;
acute and prophylactic management
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brand names/dosing strengths for divalproex
- depakote (DR) 125, 250, 500
- depakote (sprinkle capsule) 125
- depakote (ER) 250, 500
- depakene 250
- depakene 250mg/ml
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dosing range for valproic acid
750-3000mg/day (20-60 mg/kg/day)
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valproic acid ADEs
- nausea/anorexia
- wt gain
- sedation
- tremor
- rash
- alopecia
- inhibits metabolism of other drugs
- pancreatitis
- hepatotoxicity
- SJS
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lamotrigine brand name/dose strengths
lamictal 25, 100, 150, 200mg (2, 5, 25mg chewable tablet)
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lamictal usual dose
50-300mg/day
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lamictal target dose
~200mg/day
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how can lamotrigine be used
as monotherapy or add on therapy for refractory bipolar depression
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common ADEs of lamictal
- HA
- nausea
- dizziness
- tremor
- rash
- pruritis
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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
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Oxcarbazine brand name/dose strengths
trileptal 150, 300, 600mg; sus 300mg/5ml
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which drugs are not approved for bipolar disorder
carbamazine, oxcarbazine
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carbamazine, oxcarbazepine usually reserved for what type of pts
lithium-refractory pts, rapid cyclers or mixed states
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Carb/Oxcarb dosing ranges
- 200-1800mg (2-4 div doses)
- 300-1200mg (2 div doses)
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women on OC taking oxcarbazepine or carbamazepine should do what
take higher doses of oral contraceptives
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drug interactions that increase carbamazepine concentrations
- cimetidine
- diltiazem
- erythromycin
- fluoxetine
- fluvoxamine
- isoniazid
- itraconazole
- ketoconazole
- verapamil
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oxcarbazepine compared to carbamazepine
fewer ADEs and is better tolerated than carbamazepine
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FDA approved for the treatment of acute mania in bipolar disorder:
- aripiprazole (abilify)
- olanzapine (zyprexa)
- quetiapine (seroquel)
- risperidone (risperdal, consta)
- ziprazidone (geodon)
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only FDA approved option for bipolar depression
seroquel
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AAP approved for maintenance treatment of bipolar disorder
zyprexa
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what can clozapine be used for in the treatment of bipolar disorder
refractory bipolar disorder
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use of BZDs
for acute mania, agitation, anxiety, panic, insomnia, pts who cannot take mood stabilizers
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drug used for acute agitation
lorazepam (ativan)
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BZD contraindication
pts with substance abuse
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antidepressant added for:
the treatment of acute depression (can be added on)
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TCAs and SNRIs are associated with:
an increased risk for inducing mania and rapid cycling
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when should antidepressants be withdrawn
2-6 mnths
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valproate has a risk of what in the first trimester
neural tube defect
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