562 Bipolar Disorder

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whiteap
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151746
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562 Bipolar Disorder
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2012-05-02 20:00:52
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UWSOP Pharm 562 pharmacotherapy Dipiro Bipolar Disorder
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UWSOP Pharm 562 pharmacotherapy Dipiro Bipolar Disorder
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  1. What are the classifications of Bipolar disorder?
    • Bipolar I
    • Bipolar II
    • cyclothymic disorder
    • bipolar disorder not otherwise specified
  2. Define mood disorders by types of episodes
    • Major Depressive Disorder: single major depressive episode
    • Recurrent Major Depressive Disorder: two or more major depressive episodes
    • Bipolar I: Manic episode major depressive or mixed episode
    • Bipolar II: major depressive episode + hypomanic episode
    • Dysthymic dosorder: chronic subsyndromal depressive episodes
    • Cyclothymic disorder: Chronic fluctuations beteween subsyndromal depressive and hypomanic episodes (2yr for adults and 1yr for children and adolescents)
    • Bipolar Disorder not otherwise defined: Mood states do not mbeet criteria for any specific bipolar disorder
  3. Diagnostic Criteria for Episodes: Major depressive episode
    • Impairment of functioning or need for hospitalization
    • DSM-IV-TR criteria
    • >2week period of: depressed mood, loss of interest or pleasure in normal activities
    • and ≥5 of following symptoms:
    • mood: depressed or sad (adults) irritable (children)
    • decreased interest and pleasure in normal activities
    • decreased appetite, weight loss
    • insomnia or hypersomnia
    • psychomotor retardation or agitation
    • decreased energy or fatigue
    • fellings of guilt or worthlessness
    • impaired concentration and decision making
    • suicidal thoughts or attempts
  4. Diagnostic Criteria for Episodes: Manic
    • Marked impairment in functioning and need for hospitalization
    • Begins abruptly, symptoms increase over several days
    • Severe stages - bizarre behavior, hallucinations, paranoia, delusions
    • •Not drug or medication induced
    • DSM-IV-TR criteria
    • •≥1week: elevated expansive or irritable mood
    • •≥3 of the following symptoms: (4 if mood is only irratable)
    • DIGFAST
    • Distractability - poor attention
    • Indiscretion - pleasurable activities, high risk of consequences
    • Grandiosity - inflated self esteem, paranoia
    • Flight of ideas - rapid, racing thoughts
    • Actvity increase - energized, restless
    • Sleep deficit - decreased need
    • Talkative - pressure of speech
  5. Diagnostic Criteria for Episode: hypomanic
    • NO marked impairment of social or occupational functioning, delusions or hallucinations
    • DSM-IV-TR criteria
    • ≥4days: elevated expansive or irritable mood
    • ≥3 of the following symptoms (4 if only irritable):
    • IGFAST
    • Grandiosity - inflated self esteem
    • Flight of ideas - rapid, racing thoughts
    • Actvity increase - energized, restless
    • Sleep deficit - decreased need
    • Talkative - pressure of speech

    • can switch to manic episode
    • pts are usually more productive and creative
  6. Diagnostic Criteria for Episode: Mixed
    • Impairment of functioning or need for hospitalization
    • DSM-IV-TR criteria
    • ≥1week of daily symptoms
    • both major depressive disorder and manic episode
    • comorbid alcohol and substance abuse, severe anxiety, higher suicide rate, poorer prognosis
    • young old and women
  7. Diagnostic Criteria for Episode: rapid cycling
    • Impairment of functioning or need for hospitalization
    • DSM-IV-TR citeria
    • >4 episodes in 12 mos (major, manic, hypomanic or mixed)

    • 10-20% of bipolar patients are rapid cyclers
    • poorer prognosis and response
    • Risk Factors: alcohol, antidepressants, stimulant use, hypothyroidism, menstral
  8. Which mood episode is not characterized by an impairment of social or occupational functioning, or have a need for hospitalization to prevent self-harm, harm to others or presence of psychotic symptoms?
    Hypomania
  9. What is the difference between manic and hypomanic mood episodes?
    • manic episodes are more severe than hypomanic episodes
    • hypomanic - no marked impairment of function, delusions or hallucinations - duration is less
  10. Suicide attempts occur in what percent of patients with Bipolar disorder? Which bipolar disorder type is more likely to attempt suicide?
    • 50%
    • Type II is more likely to attempt suicide than type I
  11. What are the non-pharmacological treatments for Bipolar Disorder
    • Therapy: psychotherapy, interpersonal, cognitive behavioral
    • reduce stress
    • sleep
    • nutrition
    • exercise (3xwk)
    • ECT: severe mania, mixed episodes, psychotic depression, rapid cycling, poor responders
  12. Treatment: Acute Mania in bipolar disorder
    • Mood Stabilizers
    • Lithium
    • Valproic Acid (valproate, divalproex sodium)
    • Carbamazepine ER
    • FGA's & SGA's: mono or +lithium/VPA
    • Aripiprazole
    • olanzapine
    • quetiapine
    • risperidone
    • ziprasidone
    • haloperidol
    • Alternatives: HD benzos (clonazepam and lorazepam)
  13. Treatment: Acute Bipolar Depression
    • Quetiapine
    • Lamotrigine - mono and add-on for refractory bipolar depression
    • Alternatives: Antidepressants (TCA's and venlafaxine can induce mania in bipolar I) w/d 2-6 mos after remission
  14. Treatment: Bipolar Maintenance Therapy
    • Mood Stabalizers
    • Lithium
    • VPA
    • Carbamazepine
    • Lamotrigine - bipolar I, mono and adj. in refractory bipolar depression
    • SGA's
    • aripiprazole
    • olanzapine
  15. Treatment: rapid cycling
    • Valproate
    • Alternative: Nimodipine (anticonvulsant properties, high lipid solubility, good penetration to brain)
  16. Drug of choice for euphoric mania
    Lithium
  17. Drug of choice for mixed, irritable/dysphoric mania and rapid cycling
    Valproate
  18. What percent of women relapse postpartum
    20-50%
  19. Is breastfeeding okay for women taking lithium? What about Valproate?
    Lithium - It is discouraged, babies concentrations are between 10& 50%

    VPA - it's okay but baby should be monitored
  20. Which is safer for avoiding nerual tube defect during the first trimester of pregnancy, Valproate or Carbamazepine?
    • Valproate risk is ~5%
    • Carbam. risk is ~0.5-1%

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