BD (MT 2)

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  1. Medical disorders that can result in a manic episode (5)
    • 1. brain (tumors, damage...)
    • 2. Infections
    • 3. Metabolic disorders ( NB: Hyperthyroid)
    • 4. Seizure disorders
    • 5. Degenritive DOS in CNS
  2. Certain drugs/substances can cause manic episodes?(7)
    • 1. Psychostimulants
    • 2. Too much Thyroid hormones, such as levothyroxine
    • 3. Some antihypertensive medications
    • 4. Corticosteroids such as prednisone
    • 5. Isoniazid
    • 6. Procarbazine
    • 7. S-adenosylmethionine (SAMe)
  3. Can cause manic episodes Antidepressants how? (3)
    • 1. Manic induction or “Manic push: Tricyclic antidepressants and SSRIs can trigger mania in some
    • 2. SRRI abrupt withdrawal
    • 3. Manic induction (false mania)
  4. See combination of several classes of drugs at one time (3 combos)
    • 1. SSRIs and mood stabilizers
    • Some argue SSRIs for short term, some always
    • 2. Atypical antipsychotics and SSRIs
    • 3. Anticonvulsants and SSRIs
  5. With typical or classic mania drugs of choice (2)
    lithium or valproate
  6. Goals of Psychopharmacologic Treatment of Bipolar Disorders (4)
    • 1. Prevention of relapse
    • 2. Reduction of mood symptoms
    • 3. Reduction of risk for suicide
    • 4. Treatment of bipolar patients does not end with the
    • prescription of mood stabilizing medications (stress big issue with depression)
  7. Lithium Carbonate (do what in bp)?
    Useful for reducing the frequency and severity of recurrent bipolar episodes
  8. Three Hypotheses for Action in Lithium?
    • 1. Biogenic Amine Hypothesis: Lithium may exert its therapeutic effect by modifying membrane excitability via an ionic mechanism. Intriguing, yet inconsistent
    • evidence that Li+ competes for Ca2+ binding sites

    2. Electrolyte Hypothesis: Biogenic Amine Hypothesis Li act with monomine. Lithium’s actions may be related to its ability to modulate serotonin and/or norepinephrine function

    3. 2nd Messenger System Hypothesis: “Lithium alters the transduction of the neurotransmitter-initiated signal by modifying the function of second messengers". Lithium may reduce the post-synaptic actions of 5-HT and NE on second messenger systems.
  9. Pharmacokinetics of lithium: issue with kidneys vs. liver?
    Processed and cleared by kidneys (not liver): Excreted in its intact form via kidney (95%), sweat, saliva and breast milk (5%)
  10. Therapeutic index of lithium and blood level vs. dosage?
    • 1. Narrow therapeutic-toxic ratio (i.e., low therapeutic index)
    • 2. Blood level is more important than the dosage
    • Dosage is adjusted according to age, renal function, lithium level and clinical response
  11. Lithium toxicity – symptoms (3), what produces it pharmacokinetically?
    • 1. a. Flu-like symptoms
    • (Worsened nausea, vomiting, diarrhea, muscular weakness)
    • b. Muscle twitching, drowsiness, confusion, arrhythmia, coma, convulsions, death
    • c. CNS effects
    • (Disorientation, confusion, tinnitus (ringing in the ears),
    • worsening of hand tremor, slurred speech, ataxia (gait incoordination), muscle twitching, delirium,
    • seizures, coma)
    • 2. Inadequate fluid intake increases likelihood of toxicity

    lDiuretics will do this as well (have to balance fluid)

    lMUST discontinue the drug immediately
  12. Lithium interactions w/ diuretics (2)
    • Diuretics will increase lithium levels by retaining lithium
    • and eliminating water.
    • Sodium trade off with lithium.
    • Give up sodium à increase retention of lithium. Diuretics (sodium loss) à more lithium à go toxic:
    • 1..Coffee – diuretic effect <NB
    • 2. Alcohol – diuretic effect <NB
    • Diuretics (sodium loss) à go toxic Combination with tobacco
    • Nicotine accelerates the metabolism of caffeine (coffee)
    • While still smoking need to drink more coffee to get caffeine effects
    • Get increased diuretic effect from fluids alone à go toxic
    • If quit smoking, can have dramatic rise in caffeine levels à go toxic
  13. Lithium interactions? (5)
    • l. Combination with SSRIs
    • -Combination will increase risk of
    • serotonin syndrome
    • 2. Combination with TCAs (raise the level of TCA increasing effects)
    • -Neurotoxic effects
    • -Even at normal doses of lithium and TCA
    • 3. Muscle relaxants
    • -prolongs effects of lithium à go toxic
    • 4. Phenothiazines
    • -decreases levels of phenothiazines
    • 5. Non-steroidal and anti-inflammatory drugs
    • -increase lithium retention à go toxic
  14. Issue of drugs as off-label or on-label?
    • FDA has NOT given approval of these drugs
    • This type of medication usage is known as "off label"
    • Important to recognize "off label" usage is generally
    • considered an option only after all traditional treatment methods have failed (can use but more risk/ some used as part of treatment)
    • -new drugs work differently for different people and each has its own unique side effects
    • These drugs have not been approved by the (FDA) for the treatment of bipolar disorder
  15. Anticonvulsants and BD Lamitcal – effects and
    side effects and interactions(2)?
    • -Fewer side effects than lithium
    • 1. Side effects: headaches, rash,
    • dizziness
    • -Rare but dangerous severe rash: Stevens-Johnson syndrome
    • 2. SE: -with ETOH
    • -Psychomotor impairment
    • -Lower seizure threshold
    • -CNS depression
    • -. with carbamazepine
    • -decrease Lamictal levels
    • -increase likelihood of cognitive problems
  16. Tegretol – effects and side effects and interactions?
    • (Experimental or off label (no FDA approval for BlRapid cycling BD (4+/yr))
    • 1. Side effects like TCAs
    • 2. a. Do NOT use with Serzone – dangerous interaction
    • -Serzone causes liver toxicity
    • b. Negative interactions with Prozac, Luvox, and lithium
    • -mandatory regular blood count monitoring
    • and periodic liver function tests. several adverse interactions can occur when combined with other drugs due to induction of liver enzymes
  17. Tegretol: ADVANTAGES (5)
    • 1. Strong acute efficacy data
    • 2. Broad activity spectrum
    • 3. Possible antidepressant effects in bipolar disorder
    • 4. Long history of use
    • 5. No weight gain
  18. Tegretol: DISADVANTAGES (5)
    • 1.May lose effectiveness over the long-term
    • 2. Drug interactions
    • 3. Blood disorders
    • 4. Narrow therapeutic index
    • 5. Acute side-effects
  19. Signs of overdose with anticonvulsants? (6)
    • 1. CNS signs
    • 2. Somnolence, seizures, coma
    • 3. Gastrointestinal symptoms
    • 4. Severe nausea and vomiting
    • 5. Cardiac signs
    • 6. Arrhythmias
  20. New information from FDA regarding warning on anticonvulsants (4)
    • l. CNS signs
    • -Confusion
    • 2. Renal signs
    • -Urinary retention
    • 3. Hematological signs
    • Bone marrow suppression
    • 4. suicidality
  21. Use of antipsychotics for BD – acute use vs. chronic and which drugs are used
    • 1. Classic Antipsychotics: Used for very short term control of excessive psychotic behaviors
    • 2. Atypical Antipsychotics: bipolar patients manifest
    • psychotic symptoms, either during manic or depressive episodes as monotherapy for episodes of mania or bipolar depression
  22. Use of atypical antipsychotics (3)?
    • 1. Atypical Antipsychotics: either during manic or depressive episodes
    • 2. as monotherapy for episodes of mania or bipolar depression
    • 3. May also be useful for relapse prevention and maintenance treatment
  23. Psychotherapy issues for BD and medical management?(5)
    • compliance is a big issue
    • 1. people miss their highs
    • 2. life is "boring" without them
    • 3. serious side effects
    • 4. difficulty with polypharmacy
    • 5. often see many changes in meds
  24. Compliance problems – how to help this
    • Components for psychoeducational protocols:
    • 1. Education about BD
    • 2. Relapse prevention
    • 3. Medication compliance
    • 4. Communication skills training
    • 5.Research on family-based interventions (Falloon):
    • lower rates of family separations
    • greater improvements in level of family functioning
    • higher rates of full recovery
    • lower rates of rehospitalization for 2 years post-rx
    • Over critical hyper involved family more issues
  25. Family based interventions for BD
    Research on family-based interventions (Falloon): lower rates of family separationsgreater improvements in level of family functioninghigher rates of full recoverylower rates of rehospitalization for 2 years post-rx Over critical hyper involved family more issues
  26. Use of BD medications for cyclothymia
    • 1. Somewhere between Bipolar and normal experience:
    • -Hypomanic episodes
    • -Some depression, but not the full depth of disorder
    • -Must have the disorder for at least 2 years before it is
    • diagnosed
    • -Must be chronic
    • 2. Do not have evidence for effectiveness of medications here (NO DATA just
    • basic Sx relief)
    • Have tried lithium and valproic acid
    • Psychotherapy is indicated (characterological problems)
  27. Use of BD mediations for borderline personality disorder
    • No research evidence for effectiveness of this approach
    • : Based on idea by Akiskal that BPD is subtype of BD (e.g.,
    • Bipolar 5)
Card Set
BD (MT 2)
Exam notes for Psychopharmacology
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