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168 Cards in this Set
- Front
- Back
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Episode- A major depressive episode
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Major depressive disorder, single episode
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Episode- A major depressive episode + a major depressive episode
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Major depressive disorder, recurrent
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Episode- Major depressive episode + manic or mixed episode
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Bipolar I
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Episode- Major depressive episode + hypomanic episode
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Biplolar II
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Episode- Manic or mixed
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Bipolar I
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Chronic Subsyndromal depression
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Dysthymic disorder
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Chronic fluctuation between subsyndromal depression and hypomania
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Cyclothymic disorder
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Diagnostic Criteria
Manic episode |
A) a distinct period of abnormally and persistent elevated, expansive or irritable mod, lasting 1 week
B) during the period of mood disturbance, three or more of the following have persisted and 4 if the mood is only irritable and to a significant degree 1) inflated self-esteem 2) decreased need for sleep (need only 3 hours ) 3) more talkative than normal 4) flight of ideas or subjective experience that thoughts are racing 5) distractiblity 6) increase in goal-directed behavior (social/school, work, sexually) 7) excessive involvement in pleasurable activities that have a high potential for painful consequences C) do NOT meet criteria for mixed episode D) marked by a severe impairment in funcitoning or in activities or relationships with others |
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Diagnostic Criteria
Hypomanic episode |
A) A distinct period of persistently elevated or expansive or irritable mood lasting at least 4 days that is different from non-depressed mood
B) during the period of mood disturbance, three or more of the following have persisted and 4 if the mood is only irritable and to a significant degree 1) inflated self-esteem 2) decreased need for sleep (need only 3 hours ) 3) more talkative than normal 4) flight of ideas or subjective experience that thoughts are racing 5) distractiblity 6) increase in goal-directed behavior (social/school, work, sexually) 7) excessive involvement in pleasurable activities that have a high potential for painful consequences C) do NOT meet criteria for mixed episode D) is NOT marked by a severe impairment in funcitoning or in activities or relationships with others |
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Diagnostic criteria
Mixed episode |
Criteria are met for a manic and for a major depressive episode (except for duration) everyday for at least one week
Mood is severe to cause impairment |
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Rapid-cycling specifier
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At least 4 episodes of mood disorder in the previous 12 months
Episodes are demarcated by partial or full remission for at least 2 months or a switch to an episode of opposite polarity |
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Bipolar I single manic episode
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Presence of only one manic episode and no past major depressive episodes
Note- a recurrence is defined as either a change in polarity from depression or an interval of at least 2 months without manic symptoms |
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Diagnostic criteria-
Bipolar II |
Presence of or history of one or more major depressive episodes
Presence of or history of at least one hypomanic episode |
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What is the lifetime risk of Bipolar 1 disorder
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0.2-0.9%
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Lifetime risk of biolar I and II
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1.2%
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Onset of bipolar __-__?
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15-30
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Most studies indicate BP will have ___ ore more episodes in a lifetime
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4
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Rapid cycling has __ a year and __ in a lifetime
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4, 50
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BP episode length ranges from __- ___ months
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4-13
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What sex predominates the rapid cycling and at what %
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Woman, 70-90%
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how many Bipolar patients do not respond well to lithium
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20-40%
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Prognosis of BP I
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7-32% remain chronically ill
26% with good outcome 40% moderate 34% poor outcome |
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Prognosis of BP II
after 5 years__% relapse and __ are relapse free? |
After 5 years 70% multiple relapse and 11% episode free
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What % gain control of disease with medications in BP
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50%
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What 4 factors are a poor prognosis with BP
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1. Comorbid substance
2. Interepisode depressive features 3. psychotic features 4. Male gender |
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What are the 2 factors in better prognosis in BP?
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More advanced age onset and short duration of manic episodes
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How many pts with BP develop rapid cycling
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10-20%
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What % of woman are rapid cyclers
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70-90%
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What is the difference between Bipolar with psychotic features and Schizoaffective D/O
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BP- Psychotic features limited to mood episode
Schizoaffective- psychotic features during normal moods for 2 week period |
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Differential Diagnosis
What 6 neurolgogical medical disorders can cause mania |
stroke, headtrauma, dementia, brain tumor, infection (HIV), MS, Huntington's disease
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What endocrine 2 issues can cause mania
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hyperthyroidism
postpartum |
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What endocrine disorders 5 can cause depression
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addison's, cushings, hypothyroidism, hyperthyroidism, postpartum
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What metabolic deficiencies 2 can cause depression
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folate and B12
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What 2 high bloodpressure meds can cause depression
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Alphamethyldopa, Clonondine
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What 2 ulcer meds can cause depression
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Cimetadine, Rantitidine
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What hormones can cause depression 3 (meds)
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Corticosteroids, Oral contraceptives, Anabolic steroids
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What psychotropic 2 meds can cause depression
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benzodiazepines, neuroleptics
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DSM
What are the 5 meds used to treat acute BP |
Lithium
Carbamazepine Valporate Olanzapine Verapamil |
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DSM
What are the two drugs to treat acute BP depression |
Lithium
Lamictal |
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DSM
What is propholaxis in treating Mania and depression |
Lithium
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Algorithm for rapid cycling
#1 line- Drug class? 2nd line- switch or combine _____ class? 3rd- if still add high dose of ___? 4th- consider___ |
#1 anticonvulsants
#2 if still- switch or combine anticonvulsants #3 if still add high dose T4 thyroxine #4 if still consider ECT |
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What 2 drugs can lead to lithium toxicity
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diuretics (thiazide) and NSAIDS
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How do you begin lithium treatment? Start out at ___mg for ___ days? Then on day __, __ hours after last dose draw ___ level?
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300mg 2-3 x QD
5 days day 6 12 hours trough |
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What is the max a day lithium dose?
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1800
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Can you take Lithium in pregnancy?
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NO
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What is first line monotherapy for mixed or manic episodes without psychosis
a) __ or ___? b) if moderate to minimal improvement _______ or_______? c) Some think you have to start with a ______ first? My combine ___ # of meds if needed? |
a) traditional mood stabalizer or atypical antipsychotic
b) if moderate to minimal improvement add a second mood stabalizer or an atypical antipsychotic c) some think you have to start with mood stabazlizer first MAY combine 3 meds if needed |
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How long must you wait post manic before adding a stimulant or antidepressant
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2 weeks
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When is lithium not recommended in BP
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rapid cycling or mixed
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What % respond to lithium as long term maintenance monotherapy
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25%
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What are the two benefits of using atypical antipsychotics in BP
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1) core non-psychotic symptoms of mania
2) prevention of the recurrence of depression |
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How does Lamictal effect Depakote levels
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it decreases depakote levels
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What is the typical dose of Lamictal and how do you start treatment? What is the max dose?
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25mg QD for 2 weeks and increase by 25 mg for week 2 and week 3 increase to 100mg
MAX dose 200mg |
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what one drug and what class of drugs are used to treat anxiety in BP
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neurontin and benzo's
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What 2 mood stabilizers would you give if weight was an issue?
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topirmate or zonisamide
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What 10 agents are used for BP mania
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Abilify, Saphris, Tegretol, Thorzine, Depekote, Lithium, Zyprexa, Seroquel, Risperedol, Geodon
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What 2 medications are used to treat BP depression
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Olanzapine + Fluoxetine =Symbyax
and Seroquel |
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What 6 meds are used in BP maintenance or propholaxis
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Abilify, Lamicital, Lithium, Zyprexa, Risperdal, Geodone (adjunct)
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What 5 symptoms can classify 83% of BP symptoms
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reckless activity
distractibility agitated activity irritable mood and increased self-esteem |
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What % of time do BP 1 pts spend
hypo or manic depressed cycling/mixed asymptomatic |
9.3%
31% 6% 52% |
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What amount of time do pts spend in BP 2 spend
hypomanic depressed cycling or mixed asymptomatic |
1.3%
50% 2.3% 46% |
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What % of BP patients will experience a mixed episode
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40%
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What hypomanic symptoms are most often associated with major depressive episode (mixed episode) (6)
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irritablity
risky activities racing or crowded thoughts psychomotor agitation distractibility suicidality |
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what major depressive symptoms are associated with mixed states of BP with hypomania ( 8)
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weight gain
overeating hypersomnia worthlessness guilt diminished concentration indecisiveness thoughts of death |
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rapid cycling
A period of __ months between a switch from manic to a depressive episode OR full remission is required |
2
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in Rapid cycling and episode of mania has to last__? hypomania___? and depression___?
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mania-one week
hypomania-4 days depression-2 weeks |
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What % of BP patients exhibit rapid cycling
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10-30%
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What % of rapid cyclers are woman
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70-90%
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When people are misdiagnosed as having unipolar depression what % of people treated with an antidepressant will go on to develop hyomania, and__% rapid cycling
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50%
25% |
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What 3 drugs are most effective in treating both mania and depression in BP
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Lithium, lamictal, and Seroquel
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According to the APA the treatment of Acute mania or mixed episodes is treated with __ or __?
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Li in combo with AP or Val in combo with AP
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According to the APA less severe episodes of mania and mixed episodes is best treated with __ or__?
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Second Generation AP better than First Generation AP
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Alternatives according to the APA are one of 3 drugs
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Tegretol, Geodon, or Seroquel
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What is the treatment in refractory cases of BP according to the APA
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Cloz + ECT
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According to the APA what is the best treatment for acute depression? inititate with ___ or ___?
consider ____ with _____ |
Initiate with Lithium or Lamictal
Consider lithium with antidepressant |
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In severe cases what is the treatment for acute depression? and if unresponsive add?
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ECT
add another Antidepressant |
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According to the APA what is the maintenance treatment of BP___ 4 meds and __?
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Lithium
Valproate Lamictal Tegretol or maintenance ECT |
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FDA approves what 9 drugs for acute mania
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abilify
tegretol ER Thorazine depekote ER lithium zyprexa seroquel risperdal geodon |
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The only monotherapy approved by the FDA to treat BP depression is
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Seroquel
and Zyprexa + Prozac = Symbyax |
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The FDA approves what 5 drugs for the maintenece treatment of BP
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Abilify
Lithium Valproate lamictal zyprexa |
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What drug risks of developing PCOS
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Depakote
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What drug has tetrogenic side-effects
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tegretol
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What is the MOA of Lithium
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Complex; alters sodium transport across cell membranes in nerve and muscle cells; inhibits NT via phosphaitdyl inositol 2nd messanger system
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FDA approval for Lithium (3)
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manic episodes
maintenance manic depression with a history of mania (BP depression, adjunctive treatment in major depression, vascular headache and neutropenia) |
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What is the acute dosing for Lithium
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1800mg in 3 divided doses
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What is the maintenance dose for lithium ___-___ or ___ (+time)?
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900-1200 mg in divided doses OR all at night
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What is the starting dose of Lithium?
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Start at 300mg 2-3 times a day then increase dose while monitoring plasma levels
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What are the most common side-effects with lithium (10)
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ataxia, dysarthria, delerium, tremor, memory problems, polyuria and polydypsia (nephrogenic diabetes insipidus, diarrhea, nausea, weight gain
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What are the life-threatening changes in lithium toxicity
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renal impairment, cardiovascular changes
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What are the special considerations to know with Lithium (4)
dose related___ elderly need___ dose Preg __ breast feed__ |
1) narrow window
2) elderly need lower dose 3) risk D pregnancy 4) do not breast feed |
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What is the MOA of lamictal
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blocks VSSC's; interacts with open channel conformationof VSSCs at the alpha pore forming subunit, inhibits Glutamate release
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What is the FDA approval for Lamictal
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Maintenance treatment of BP 1
(BP Depression, BP mania, adjunctive and 2nd line) psychosis, adjunctive tx in schizophrenia) |
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What is the dose of lamictal for monotherapy in BPD
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100-200mg day
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What is the dose of Lamictal as an adjunctive treatment
in combo with depekote in combo with tegretol |
BPD- 100mg day in combo with depekote
or 400 mg a day in combo with tegretol |
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What is the starting dose and titraition of Lamictal
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Titrate VERY slow up to 200mg a day
25 mg for 2 weeks 50 mg wk 3 100mg aday at week 5 200mg a day at week 6 |
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What is the reaction of combo of lamictal and depakote
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Doubles level of lamictal and reduces the level of depekote in half
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what are the most common side effects of lamictal (13)?
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rash 10%
sedation blurred vision dizziness ataxia headache tremor insomnia poor coordination fatigue nausea vomiting abdominal pain |
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What is the life threatening side effect of lamictal
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rash
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What are the special considerations in using Lamictal?
caution with ___, ___ and ___ impairments Population___? Pregnancy category? |
caution with - renal, hepatic or cardiac impairment
elderly lower dose Cat C pregnancy no breast feeding may be the BEST drug to treat BP depression and mania to prevent relapse |
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What is the mode of action of Carbamazepine (Tegretol)
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blocks VSSC, interacts with open channel conformation of VSSC at the alpha pore forming unit, inhibits glucagon release
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What is the FDA approve the use of Carbamazepine (tegretol)
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mania in BPD (AS a controlled release formulation)
(bpd, psychosis, adjunctive tx in schizophrenia) |
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What is the dose and titrate of tegretol
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400mg a day, increased slowly up to 1200 mg a day to enhance tolerability of sedating SE
Can require upward dosage adjustment as it induces its own metabolism, thus lowering plasma levels during the first several weeks and months of treatment |
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What are the most common side-effects of tegretol (9)
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sedation
dizziness confusion unsteadiness headache nausea vomiting diarrhea benign leucopenia (10% ) rash |
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what are the life threatening issues with Tegretol (4)
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aplastic anemia
agranulocytosis severe dermatologic reactions SIADH |
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What are the special considerations in Tegretol
monitor patients for signs of unusual___ and ___ Preg cat __ breast feed__? may be useful in people who fail to respond to ___ and ___? prefered __ and __ line treatment in mania? |
monitor patient for signs of unusual bleeding and bruising
category D pregnancy no breast feeding may be useful in people who fail to respond to lithium or other mood stablizers preferred 2nd and 3rd line treatment in mania |
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What aspect of BP is tegretol not effective for
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bp depression
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Valporate MOA is
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increases brain concentrations of GABA by blocking VSSCs
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What is the FDA approval for Valproate
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Mania, migraine prophylaxis, maintenance tx BP
(non-FDA off label) (bp depression, psychosis, adjunctive tx in schizophrenia |
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What is the dose and titration of depekote
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varies widely
750-3000mg day for acute mania start at 1000mg and increase rapidly for less acute start at 250-500 and titrate upward as tolerated, can go up to 1200-1500 a day |
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What are the 12 most common SE with depekote
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sedation
tremor dizziness ataxia asthenia headache abdominal pain nausea vomiting diarrhea constipation alopecia (unusual) |
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what are the lifethreatening issues with depekote
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rare hepatoxicity with liver failure and fatal pancreatitis
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What are the special considerations with depekote
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be alert to hepatoxicity and pancreatitis
elderly need lower dose pregnancy risk D okay for breast feeding |
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what is the best and first line treatment for patients with mixed states of BP or with rapid cycling
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depekote
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Is depekote more effective for preventing mania or BP depression
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preventing mania
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What 3 target symptoms is depekote used to treat in BP and schizophrenia
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aggression, agitation and impulsivity
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What do you do when you give Depekote with Lamictal
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reduce lamictal to half the dose as valproate can double lamictal levels
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Thorazine or Chlorpromazine MOA
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blocks D2 recpetors, combo of D2 and H1 and cholinergic M1 blockade in vomiting center may reduce nausea and vomiting
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What is the FDA approval for Chlorpromazine
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Schizophrenia, manic type of manic depression, combativeness and or explosive hyperexciteable behavior in children, hyperactive children, acute mania
(BPD) |
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What is the dose of Thorazine
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200-800mg a day
low dose has more sedative effects one of the few available as a suppository |
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What are the most common sideeffects of Thorazine 19
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neuroleptic-induced deficit syndrom
akathisia priapism EPS Parkinsonism TD galactorrhea ammenorhea dizziness sedation impaired memory dry mouth constipation decreased sweating sexual dysfunction hypotention weight gain tachycardia syncope |
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what is the life threatening consideration with Throazine
(4) |
rare neuroleptic syndrome
rare jaundice agranulocytosis rare seizures |
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SC with Thorazine
preg risk___ caution with ___, ___ or ___ impairment breast feed??? |
Caution with renal, cardiac or hepatic impairment
Preg category C no breast feed |
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What is the MOA of Geodon (Ziprasidone)
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blocks D2, and 5-HT receptors; interactions at 5-HT2c and 5-HT1a and 1d receptors ma contribute to efficacy in cognitive and affective symptoms
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What is the FDA approved use of Geodon
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Schizophrenia
acute mania mixed episodes (BP maintenance, BP depression, disorders of impulse control, psychotic disorders) |
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What is the dose of Geodon
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80-160 mg a day in divided doses
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What is the titration of Geodon
start at __mg BID, day 2 increase to __-__ BID too low a dose will block ____receptors and cause____? best dose efficacy seen at doses higher than ____? Best taken with or without food? why? |
start oral dose at 40mg 2x's a dayon day 2 increase to 60-80mg 2 x a day
too low a dose might block 5-HT 2c receptors, best efficacy seen at doses higher than 120 best if taken with food as food can double the bioavailablity by increasing absorption and increasing plasma drug levels |
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What are the most common SE of Geodon (10)
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dizziness
EPS sedation dystonia nausea dry mouth ashenia skinrash rare TD orthostatic hypotention |
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What is the life-threatening issues with Geodon
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rare neuroleptic malignant syndrome seizures
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SC with Geodon
dose adjustments ? no use in ____patients Preg risk__ Breast feed? More activating at what dose low or high? |
no dose adjustment needed in patients with renal or hepatic
NO use with cardiac pts Preg risk C no breast feed more activating at low doses |
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Abilify MOA
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D2 partial agonist; D3 agonist, 5-HT 1a partial agonist, 5-HT2a antagonist which can lead to enhanced DA release in certain brain regions
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What is the FDA use of Abilify
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Schizophrenia and maintaining stability in schizophrenia, acute TX of BP mania and mixed states
(BP depression, various behavioral disturbances, disorders of impulse control, BP maintenance) |
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What is the dose for Abilify
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15-30 mg a day
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What is the titration of Abilify
__-__mg a day? lower or higher dose needed to avoid akathisia if pt switched from AP to abilify consider adding ___ dose of ablify to the ___ dose of the 1st AP for several days prior to slow down titration of 1st drug |
lower doses may be needed to avoid akathisia/activation for max tolerability
if pt is being switched form AP to abilify consider adding a full dose of abilify to the maintenance dose of 1st AP for several days prior to slow down titration of the 1st drug |
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What are the most common SE with Abilify (7)
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dizzy
insomnia akathisia activation nausea vomiting occasional hypotension Theoretical TD risk |
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Life threatening SE of Abilify
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NMS, seizures
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SC of Abilfy
dose adjustment needed? preg cat__? weight? sedation? metabolic risk? |
dose adjustment no needed in renal or hepatic pts
Preg category C less weight gain less sedation low metabolic disease risk |
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MOA Olanzapine
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blocks D2 and 5-HT 2a receptors causing site-specific enhancement of DA release, has antagonist actions at 5-HT 2c receptors
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What is the FDA approval of Zyprexa
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Schizophrenia and maintaining response, acute agitation, acute mania, BP maintenance, BP depression
(other psychotic disorders, AD-resistant unipolar depression, various behavioral disturbances, disorders of impulse control) |
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What is the typical dose of Zyprexa
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10-20mg a day
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What is the titration of Zyprexa
start at __-__ mg a day then increase by ___ mg a day for ___(how long) until desired efficacy. |
start with 5-10 mg once a day then increase by 5mg a day 1 x a week until desired efficacy
raising the usual dose to 15 mg may be good for agitation or treatment resistance with little SE for non-responders increase dose to 30mg a day (approved only for 20mg a day though) |
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Common SE of Zyprexa (13)
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DM and dyslipidemia
dizzy sedation dry mouth constipation weight gain joint, back and chest pain abdormal gait peripheral edema tachycardia orthostatic hypotention rare TD rare rash with sunlight |
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What are the Life-threatening issues with Zyprexa (7)
3- bloodsugar elderly___ |
Hyperglycemia
rare ketoacidosis hypersomolar coma and death Stroke mortality increased with elderly in dementia related psychosis NMS rare seizures |
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What are the special considerations with Zyprexa
Woman have a ___ clearence? dose adjustment for hepatic and liver? any renal risk or dose adjust? increased risk of a ___ in elderly Preg risk cat ___ Augment with ___ in BP depression smoking ____levels? |
Woman have a decreased clearance
lower dose if hepatic and monitor liver function no adjust for renal increased risk of stroke in elderly Cat c pregnancy Augment with Prozac in BP depression smoking decreases levels |
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Seroquel or Quetiapine MOA
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MOA
blocks D2 and 5 HT2a recpetors causing specific enhancement of DA release that also acts at 5HT 1a receptros which could improve cognitive and affective symptoms |
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FDA for Seroquel
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Schizophrenia, acute mania, BP depression
(other psychotic disorders, BP maintenance, BP depression, impulse control) |
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Dose of Seroquel for acute BP mania
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For acute BP mania 400-800mg a day in divided doses
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Seroquel titrate
1st day start dosing with BID 50mg (max 100mg QD). Increase in increments of ____mg a day to ___mg a day on day 4. Adjust dose up to ____mg a day by day 6 |
on 1st day start dosing with 2 times a day with max of 100mg a day totalthen increase in increments of 100mg a day to 400mg a day on day 4 adjust dose up to 800mg a day by day 6
it is often underdosed, initital doses of 400-800 might optimize chances of success in acute mania, higher doses generally achieve greater response and some patients may need more than 800-1000mg a day |
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What are the most common S/E of Seroquel
9 |
risk of diabetes
dizzy sedation drymouth constipation abdominal pain weight gain tachycardia orhtostatic hypotention |
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Life threatening issues with Seroquel
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Hyperglycemia and ketoacidosis or hypersomolar coma and death
rare NMS |
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Seroquel SC
no dose adjustment in patients with ____ impairment downward dose adjustment in patients with ____ impairment Preg risk ___ preferable to _____ class in pregnancy breast feeding? induces more___ than other AP but no ____ SE or ____ elevation? |
no dose adjustment in patients with renal impairment
downward dose adjustment with patients with hepatic impairment Pregnancy risk C preferable to anticonvulsants in pregnancy no breast feeding induces more sedation than other AP BUT no motor SE or prolactin elevation |
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What 2 diseases is Seroquel good for in psychosis of
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Lewybody dementia and Parkinsonism
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Risperdal MOA
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blocks D2 and 5HT 2a causing site specific enhancement of DA release, alpha 2 antagonist properties may lead to AD action
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What is Risperdal FDA approved for
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Schizophrenia and delaying relapses in schizophrenia, acute mania, other psychotic disorders
(BP maintenance, BP depression, impulse control) |
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What is the dose of Risperdal
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2-8 mg a day for acute psychosis or BP
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what is the titrate for Risperdal
start with __mg a day in ___doses increase each day by __mg until desired efficacy is reached max effect seen at __-__mg MDD___ mg a day |
start with 1 mg a day in doses, increase each day by 1 mg until desired efficacy is reached. MAX effect seen at 4-8mg day
max oral dose 16 mg day best efficacy seen at 2-6mg a day |
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What are the most common SE of risperdal (13)
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diabetes
dose dependent EPS dose related hyperprolactemia rare TD dizzy insomnia headache anxiety sedation sexual dysfunciton weight gain consitpation tachycardia |
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What are the LThreatening issues with Risperdal
1) 2) elderly 3) rare |
hyperglycemia, ketoacidosis or hypersomolar coma and death, stroke
HIGH risk of mortality in elderly patients with dementia related psychosis rare NMS |
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Risperdal SC
if ___ or ___ impairment start dose at ___ BID then after ___ week increase dose to ___ BID Problematic in _____ and _____ diseases? |
If renal or hepatic impairment start dose at 0.5 BID then after one week increase to 1mg BID
PROBLEMATIC in Lewybody dementia and Parkinsonism |
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How is weight effected by Seroquel
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Weight gain is linear, lower the dose and get less weight gain.
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What is the off label dose of abilify for BP depression
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5mg
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Mood stabalizers are used in combination with __ and __ to reduce manic symptoms
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mood stabalizer and atypical
or mood stabalizer, an antipsychotic and an antidepressant |
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What are the 3 best atypicals used for BP
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risperdal, zyprexa and seroquel
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What are the Two evidence based bipolar combos
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atypical/ DPA + Lithium
atypical/DPA + Valproate |
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What are the 4 practice based bipolar combos that are not the Boston bipolar brew, the California Careful cocktail, or Tennessee mood shine
(4) |
Lithium + Valproate
Lamictal + Depekote Lamictal + Lithium Lamictal + lithium + depekote |
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Boston bipolar brew
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lamictal + Atypical+Lithium+ Depekote
NO antidepressant |
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California Careful cocktail
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same as Boston brew but + antidepressant
lamictal + Atypical+Lithium+ Depekote |
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Tennessee mood shine
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antidepressant + Atypical
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What are the Buckeye Bipolar Bullets
Stealth tx- lami-quel quel-kit modafinil combo (see next) reluctant combo |
stealth- lamictal monotherapy
lami-quel- lamictal + Seroquel reluctant- lamictal + seroquel + antidepressant Quel-kit- any seroquel combo like even with Boston brew |
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Modafinil combo 3 of them
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modafinil+ lamictal
modafinil + seroquel modafinil + lamictal + Seroquel |
