Bipolar Disorder

1. CNS disorders (MS, SLE, Brain tumor, stroke)
2. Infections (sepsis, HIV, neurosyphillis
3. electrolyte or metabolic abnormalities (hypo,hyper glycemia, Na or Ca fluctuations.
4. Vitamins and nutritional deficiences (b12, a.a. essential fatty acids)

1. Alcohol intoxication
2. Drug w/drawal.
3. Antidepressants
4. Agents that augment DA OR NE.
5. HALLUCINGENS
6. MJ intoxication
7. Steriods
8. thyroid preparations
9. Xanthines (caffeine, theophylline)
10. OTC weight loss agents and decongestants.
11. herbal products
12. Bright ligh therapy
13. Sleep deprivation

>1 wk of abnormal or persistent elevated mood with at least 3 of the following (4 if irritable):
1. Distractability (poor attention)
2. Insomnia
3. Grandiosity (inflated self-esteem)
4. Flights of Ideas/racing thoughts
5. Activity
6. Speech
7. Thoughtlessness

1. reflects the extreme mood state the patient is experiencing:
Mania:
delusion of grandiosty
Depression:
Delusions of guilt or worthlessness

At least 4 days of abnormal and persistent elevated, expansive, irritable mood associated with at least 3 of the following:
Distractability
Insomnia
Grandiosty
Flights of ideas
Acivity
Speech (Pressured)
Thoughtlessness

****NO IMPAIR FUNCTION AND DOES NOT REQUIRE HOSPITALIZATION***

FREQ or severe depression.

> or equal to 4 episodes of major depressive or manic episodes (manic, mixed, hypomanic) in 12 months.

1. meet criteria of both mdd and a ma monic episode which occurs nearly every day for at least one week.
2. femailes more common.

1. Ensure adequate sleep, nutrition, and stress reduction.
2. ECT
3. Bright light therapy
4. Excercise
5. Enviromental modification
6. Utilize adjunctive psychotherapy (individual, group, family), education, counseling.

First line therapy:
- Monotherapy with a mood stabilizer is optimal for maintenance tx.
- tx:
1. Li
2. Valproic Acid
3. Carbamazepine
4. Lamotrigine

First Line therapy FDA approved for acute mania and maintenace tx.
- for children and adults over 12 yrs old
- Add BZD until Li reaches steady state.
- Also effective in preventing and txing depression.

Long-term use reduces suicide risk 8 to 10 fold and prevents recurrent episodes of illness.

Teratogenicity
- DI: renal elimination.
- Caffeine, theophylline, acetazolamide decrease Li.
- Thiazides, NSAIDS, ACE-I, verapamil, diltiazem, salt restricted diets--> increase LI.
- additive neurotoxic effects w/ antipsychotics and antiepileptics.

1. tremor,
2. n/v (take with food)
3. weight gain
4. polydipsia/uria (nephrogenic diabetes insipidus)

- 0.6 to 1.2 meq/L for maint.
- 0.8 to 1.2 meq/L for acute episodes.

Moderate toxicity (levels>1.5
mEq/L)
1. reappearance of GI Sx.
2. severe hand tremor
3. confusion
4. hypothyroidism
5. ataxia
6. drowsiness
7. slurred speech

> 2 mEq/L:
- seizures
- CV collapse
- Coma
- Death.

First line agents: rapid cycling, mixed episodes, co-morbid substance abuse
- used in mania and main.

asa -> VPA -> WARFARIN
- VPA increased by cimetidine, chlorpromazine, erthromycin, fluoxetine.
- Inhibits metabolism of carba and lamotrigine.
- INCEARSE conc. of other anticonvulsants and TCAs

- LFTS AND CBC
- Teratogenicity: 1g/day for VPA monotherapy during pregnancy linked to 4-fold increased risk of congenital malformations

USED 2nd line:
- rapid cyclers, mixed states, Lithium- refractory patients.
- used in acute mania

Clozapine: increased bone marrow suppression
- Decreased levels/efficacy of oral conctraceptives, warfarin, VPA, lamotrigine,

inhibit Na channels and glutamate release
FDA: approved for maintenance tx.
A.E:
1.Black Box Warning: SJS
2. Titrate dose slowly

antipsychotics:
- Symbyax - bipolar depression
- black box warning for suicidality.
contraindicated w/ MAOi usage.

Risperdal for BIPOLAR MANIA
- short term tx associated with BPI in children and adolsecents 10 to 17 yrs. old