what is it called when manic and depressive symptoms COEXIST?
mixed affective episode
what is the lifetime risk of BPAD?
what is average age of onset of BPAD?
what is sex ration of BPAD?
which socioeconomic groups is BPAD assoc with and urban/rural?
what 3 categories can you split symptoms of mania into and give eg
- 1. biological:
- less need for sleep (not assoc with fatigue)
- increased energy (spending, risky business)
- increased interest in sex (disinhibition)
- general: psychomotor excitation
- 2. cognitive:
- self esteem, grandiose
- poor concentration, easily distractible
- accelerated thinking: flight of ideas, pressured speech
- impaired judgement and insight
- 3. psychotic
- thought form disorder: circumstantiality (lots of detail eventually to the point), tangentiality (never to the point),
- thought content disorder: secondary delusions (grandiose and persecutory) - mood congruent,
- abnormal perceptions: auditory hallucinations (2nd person) and sensory distortions (hyperacusis or visual hyperaesthesia)
what is the main difference between hypomania and mania?
- in mania there has to be 1 week duration of symptoms
- COMPLETE DISRUPTION OF WORK AND SOCIAL LIFE (whereas in hypomania it is not complete)
what is the differential diagnosis of elevated or irritable mood?
- MOOD DISORDERS: hypomania, mania, depression (after AD or ECT) or agitated depression
- SECONDARY TO GENERAL MEDICAL CONDITIONS: brain tumour, infarct, infection, cushiness disease, huntington's disease, hyperthyroid, MS, temporal lobe epilepsy
- PSYCHOACTIVE SUBSTANCE USE: amphetamines, antidep, cocaine, steroids, hallucinogens
- PSYCHOTIC DISORDERS: schizoaffective disorder (may be similar to mania with psychosis, but delusions are mood INCONGRUENT), schizophrenia
- PERSONALITY DISORDERS
- DELIRIUM OR DEMENTIA
what is the immediate biological treatment of bipolar / mania? (4marks)
- RISK ASSESSMENT: where what who treat (OP, CC, IP)
- 1. mood stabilisers: lithium, anti-convulsants (sodium valproate, carbamazapine, lamotrigine)
- 2. anti psychotic: olanzapine
- 3. prophylaxis: if had 2 episodes
- 4. depression: anti-depressants (but may cause secondary mania) use SSRI with mood stabiliser
how is lithium administered?
as a chemical salt - carbonate or citrate, sulphate
what is the distribution and MOA of lithium?
- small so cross BBB into CNS
- interacts with receptors to decrease noradrenaline release and increase serotonin synthesis
what needs to be done before starting lithium?
- 1. establish diagnosis
- 2. discuss need for prolonged treatment
- 3. renal and thyroid function, weight
- 4. pregnancy test (Ebsteins heart defect)
- 5. tell patient must use contraception if on Lithium as don't want to accidentally have baby then its got defect
what is the starting dose of lithium and at what time of day?
- 600-800mg nocte
- then can gradually increase dose
when do levels of lithium need to be checked again?
after 5-7 days from first starting
what is the level of lithium that is aimed for in the blood?
what are the benefits of lithium in mania?
- 1. reduce the risk of manic episodes by 30-40%
- 2. reduce the length and severity of manic episodes
how is lithium treatment monitored?
- 1. monitor mood - mood diary?
- 2. adherence or concordance with treatment?
- 3. any SE from lithium
- 4. Li level every 3 months (note every time change dose of Li, check after a week)
- 4. Renal function every 6 months
- 5. Thyroid function every 12 months
- 6. Discontinue Li slowly - otherwise risk of manic relapse
what are the SE of lithium?
- thirst- polydipsia
- metallic taste
- GI disturbance
- mild tremor
at what levels of lithium do signs of Li toxicity appear?
what are the early signs of lithium toxicity?
what are the late signs of lithium toxicity?
- severe bloody diarrhoea
what are the causes of death in Li toxicity?
- cardiac effect
- pulmonary complications
who is susceptible to Li toxicity at therapeutic levels?
- also as many on diuretics which dehydrates
what is the MOA of anticonvulsant drugs?
- enhances the actions of GABA
- may have effects on membrane excitability
give 4 indications of carbamazepine in psychiatry
- 1. treatment resistant mania or depression
- 2. treatment resistant schizophrenia
- 3. adjunct to lithium in prophylaxis of BPAD
- 4. rapid-cycling BPAD: multiple episodes >4/year
what are the adverse effects of carbamazepine? think systems…
- CNS: headache, drowsiness, diplopia
- Liver: elevation of GGT, hepatitis, cholestatic jaundice
- Other GI: N&V
- Blood dyscrasias
- Skin rashes
- Teratogenic effects - folate deficiency (spina bifida, anencephalcy)
how does carbamazepine affect other drugs?
- hepatic enzyme inducer
- so induces metabolism of:
- anticoagulants, AD, AP, OCCP, Steroids
what are the 5 MOA of sodium valproate?
- inhibit GABA transaminase
- inhibit calcium channel current
- increase GABA binding in hippocampus
- reduce action of NA at alpha2 receptors
- inhibit formation of protein kinase C
what are the indications of sodium valproate? (6)
- 1. refractory mania
- 2. rapid cycling BPAD
- 3. may have benefit in prophylaxis
- 4. epilepsy
- NB: most effective in non-psychotic patients
- may have benefit in prophylaxis
what are the SE of sodium valproate?
- weight gain
- tremor, teratogenic
what is MOA of lamotrigine?
- stabilise sodium channels
- inhibits glutamate release
what is the use of lamotrigine in bipolar?
- it is an anti-depressant in bipolar depression
- (mood stabiliser)
what are the SE of lamotrigine?
- GI problems
- CNS problems
what are the 2 major SE to be worried about in anti-psychotics?
- tardive dyskinesia
- neuroleptic malignant syndrome (medical emergency)
what are extra-pyramidal SE?
- acute dystonia: torticollis
- spasm of any muscle group esp head and neck
- akathesia: inner disccomfort and restlessness
- signs of parkinsons disease
- tardive dyskinesia: repetitive, involuntary, purposeless actions eg lip smacking, grimacing, tongue protrusion. tardive=slow onset
what are the psychosocial treatments of bipolar disorder?
- 1. bipolar prodromes: recognise early signs and symptoms
- 2. life events monitoring, diary
- 3. regulate social and sleep routines (disruption of circadian rhythms)
- 4. structured short term problem-focused therapies eg cognitive to develop new coping skills
- teach to reject negative thoughts
what are the SE of risperidone?
sexual dysfunction especially in men
what are the SE of olanzapine?
whats the median duration of a manic episode?
what is the median duration of a depressive episode?
what % of pts get chronic mania with deteriorating course?
how does mania change with age?
- remissions are shorter
- episodes more severe
which is more common mania or depression in middle aged?
depression more common and longer
who experiences more mixed affective and depressive episodes?
what is rapid cycling mania? who gets it more
- 4 or more episodes per year
- women more
what are 5 poor prognostic factors of mania/bipolar?
- young age onset
- more severe symptoms
- co-morbid: Personality disorder
- Co-morbid substance misuse
- treatment avoidance
what are the type of delusions found in depression with psychotic symptoms?
- ill health
- nihilistic delusions: pt believe something important has ceased to exist eg family no longer exists, bowel disintegrated
what is depressive stupor?
- severe depression
- slowing of movement
- poverty of speech