Bipolar

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sample Questions for MCV SOP Psych exam

What is the Lifetime prevalence of bipolar I

1% (manic or mixed episode)

incidence of bipolar II

half of bipolar 1 0.5% (hypomanic with more depressive episodes)

What is the Ratio Of males to Females with Bipolar I

Males = females for bipolar I

What is the Ratio Of males to Females with Bipolar II

Females > males for bipolar- has alot more depressive episodes

What percent of relatives have a biologic relative with a mood disorder

80-90%

What is the Monoamine hypothesis

theres too much floating around ;excess of catecholamines (NE, DA)

Valproic acid is better for treating what type of mania

Mixed Mania

Lithium is better at treating what type of mania

Euphoric Mania

when a patient is in a hospital Why do they add a BNZ in a hospital on top of Lithium and Depakote

so the patient will sleep b/c the lithium takes so long to work

How does GABA and glutamate come into play

GABA - inhibitory
Glutamate- excitory
just know where drug therapy is going

why do we believe that Ca channels are involved

b/c when we give lithium it stabilizes membrane and it works

why do we believe that kindling has something to do with the manic state

kindling in temporal lobe, multiple stressors sensitize a specific area. what types of drugs work anticonvulsants (carbamazapine)

what is one of the big causes that shows up in a CT Scan

Tumor

What autoimmune disorder can cause people to become bipolar

HIV positive- Become manic

Medications to look at
(alcohol)

ETOH withdrawal

Medications to look at
Anti depressant

unmask Mania
you can precipitate manic episode by giving AD -throws them into mania

Medications to look at
Person on Cocaine

presents as manic

Medications to look atSteroids

this lady had gotten cancer cocktail to prevent infection and it contained dexamethasone - she went wild. they treated with depakote- kirkwood lobbied against antipsych - b.c she didn't have mood disorder

Medications to look at
(herbals)

St Johns Wort

environmental conditions
bright light and sleep deprivation

if they lose sleep for a couple days can trigger
watch sleep watch what you eat dont drink

Starting Dose of Lithium

300mg TID

What is lithiums t1/2

24hrs (1 day ) so it takes 4-5 days to Steady state - if patient is outpatient she brings them back in a week and if they are inpatient she brings back in 4-5 days

Lithium has narrow range

0.8‐1.2 mEq/L acute
we push upper limit
people with mania have high elimination

Lithium andThiazides

Thiazides are the worst. they increase more than loops. we still use together but we have to watch lithium level

what NSAID is ok?

NSAIDs and COX with exception of sulindac it is her go to

dont use ACEi with Lithium

Acei increase Lithium

Low Sodium Diet

Increases lithium
if body senses low sodium it will increase lithium absorption

Lithium Side Effects

tremorNausea, diarrhea, sedation,
fatigue, ataxia, blurred vision, rash, SIADH,
Fine hand Tremor
if lithium gets toxic it beccomes course hand tremor, fatigue ataxia, acne, leukocytosis( and increase in WBC) - this is not a problem and they use it in cancer
it doesn't mean they have and infection

Lithium and Thyroid

Reduce thyroid Hormone
1) Nephrogenic Diabetes insipidus - patient going to bathroom all day long produce dilute urine - the treatment is to give a diuretic like ameloride

what labs do we need

sodium and potassium status
Scr
TSH levels
Urinalysis - look at specific Gravity

Lithium and Pregnancy

avoid lithium during first trimester
heart abnormality (epsteins abnormality (tricuspid Valve)
Fecamila - no limbs

Labs
Why Scr

if Scr is going up then you have to reduce dose of lithium based on levels

Labs Why Urinanalysis

Look at specific Gravity ( Nephro Diabetes insipidus

Depakote Dosing

have to hit hard since they dont have much time in hospital 20mg/kg (dont do baby dosing)

target blood levels of Depakote

shoot for 80-100 ng/ml

Depakote Lamotrigine interaction

increase lamotrigine levels ( increases t1/2 of lamotrigine

Depakote and Pregnancy

always check for pregnancy
the neural tube defects

Depakote and Labs

always look at LFTs and Platlets
it decreases them (thrombocytopenia)
and LFT-Hepatotoxicity - not as concerned until its 3-5 times

Carbamazapine indication

acute mania (equitro)

Carbamazapine dosing

200 mg PO BID

Carbamazapine - unique to

induces its own metabolism (levels may go down at end of month and you may have to increase dose

Carbamazapine

Cyp inhibitor of 1A2 and Cyp3A4
so it is not first line (interacts Atypicals especially Aripiprazole)

Carbamazapine AE

Rash

Depakote indication

only for Acute Mania- it does not have maintainence

Labs to monitor with Carbamazapine

Pregancy ( NTD) same as depakote
Monitor CBC with differential )(aplastic Anemia) - they couldn't control and she was always manic and she
LFT -

What if a manic Patient being treated acutely with lithium slides into a depressive episode

if they are on lithium - just increase dose - lithium is protective

What if a manic Patient being treated acutely with depakote slides into a depressive episode

depakote does not treat depression - so you add either lamotrigine (major drug interaction)
Or Quetiapine or even lithium

What is another mono therapy option for bipolar depression

Quetiapine- but it can also be used alone b/c it is a mood stabilizer

In what situation could you be forced to use depakote and lamictal

Lets say you have a morbidly obese person being acutely treated with depakote and doctor wants to avoid quetiapine to avoid weight gain

Dosing for depressive episodes of lamotrigine

if you add lamictal it gets complicated
lamictal alone goal dose is 200 mg (by week 6
lamictal with depakote goal is 100 mg by week 6)

What if a manic Patient being treated acutely with Carbamazepine slides into a depressive episode

Carbamazapine- is an inducer- if you add lamictal goal dose is 400 b/c Carb is chewing it up

Why do we titrate lamictal so slow

we are trying to avoid Steven Johnson Syndrome if you dose too quickly it could produce a rash that can progress to SJS

What is the starting dose of Lamictal

25 mg day lamictal to start

whats the problem for using AD to treat the Bipolar disorder

Might increase Rapid Cycling

When is Bupropion CId

Do not use Bupropion ever in someone who has a eating disorder or seizure disorder

whats should be obtained from 25 year old female

pregnancy test
Na
LFT
Chem 7
CBC
TSH
Tumor
Drug Screen

- neg pregnancy
- Labs look Fine
What drug Therapy

Lithium

what % of bipolar patients attempt suicide

50%

what is the • DSM-Iv Criteria for Mania

>1 week of abnormal and persistent irritable mood with 3+:

Inflated self-esteem, increased talk, racing thoughts, distractible, increased activity

What is Cyclomania

hypomania + subsyndromal depression.

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