Bipolar I Criteria
1 or more manic/ mixed episode |
Elevated, expansive, or irritable mood, and increased goal-directed activity or energy lasting ≥1 week (any duration if hospitalized), present most of the day, nearly every day |
Bipolar II Criteria
Never had a full manic episode |
At least 1 hypomanic episode and at least 1 major depressive episode |
Distinct period of abnormally and persistently elevated, expansive, or irritable mood, and increased goal-directed activity or energy lasting ≥4 but <7 days, and clearly different from usual nondepressed mood, present most of the day, nearly every day |
Not severe enough to cause marked impairment, not due to substance or medical condition, and no psychosis |
Bipolar I and II- 3 or more of the following
Grandiosity |
Decreased sleep |
Pressured speech |
Racing thoughts |
Distractibility |
Increased activity |
Excessive pleasurable activities/ risk taking |
4 required if irritable mood only
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Mania Sx- GIDDINESS
Grandiose |
Increased activity |
Decreased judgment and sleep |
Delusional |
Irritable |
Non- attentive |
Elevated mood and euphoria |
Speedy speech |
Speedy thoughts |
Demographics
0.7% population at risk |
2.3 million adults |
Age of onset in 20s normally |
= in males and females |
Treatment Guidelines
Treat to remission regardless of the number of medications |
Mood stabilizer or mood stabilizer + SGA |
Discontinue antidepressants |
Relapse risk is highest in first few months after treatment initiation |
Lithium gold standard- but less effective in rapid cycling and mixed episodes |
Meds
Lithium |
Depakote |
Tegretol |
Lamictal |
SGAs (acute mania or psychosis) |
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Lithium
Normal level 0.5- 1.2 in acute phase |
Normal level 0.6- 1.0 in maintenance phase |
Dose 1,200- 2,400mg in acute phase; 900- 1,200mg in maintenance phase |
SEs: weight gain, fine hand tremors, nausea, increased urination, thirst |
Interactions: ACEs. ARBs, diuretics, NSAIDs, Topamax |
Increase water intake |
Antisuicidal properties |
Toxicity: confusion, slurred speech, coarse hand tremors, severe GI effects |
Avoid in pregnancy (especially 1st trimester) |
Monitor KIDNEYS |
Depakote
Normal level 50-125 |
Dosage 15- 50 mg/kg/ day |
SEs: nausea diarrhea, abd cramps, sedation tremor, alopecia, liver issues |
Rare: Stevens Johnson |
Avoid in pregnancy |
Interactions: Topamax (increased ammonium), tegretol (decreases levels of both drugs) |
Increases levels of lamictal and SGAs |
Monitor LIVER |
Tegretol
Normal level 6- 12 |
Dose 10- 20 mg/kg/ day |
SEs: nausea, dizziness, sedation, headaches, dry mouth, constipation, skin rash, liver issues |
Rare: agranulocytosis/ aplastic anemia, Stevens- Johnson (In asians especially due to HLA-B 1502 allele) |
Avoid in pregnancy |
Monitor LIVER |
Lamictal
No level |
Dosage 25- 600mg/ day |
SEs: dizziness, ataxia, somnolence, diplopia, nausea, headache liver issues |
Rares: Stevens- Johnson |
Maintenance only |
Helps in depressive phases |
Titrate super slow- 25mg q day x 2 weeks, then 50mg q day x 2 weeks etc |
When added to depakote, lamictal level doubles |
When added to tegretol, it is metabolized quicker |
Often added to Lithium, SGAs or antidepressants |
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