resources - MOH

• depression most common symptom

• severe forms: unwell nearly 50% of the time

• bipolar more prevalent among maori

• mean age og onset = 17yo (+/- 4yrs)

• mild episodes of mania

  • associated with increase creativity and productivity

• cognitive disorders between epsiodes

• 15 times more likely to commit suicide compared to gen pop

• cause = multifactorial

  • inheritable

    • risk of first degree = 5-10%

    • monozygote twins 40-70%

• 1/3 diagnosed with major depression

  • depression = common

  • depression most frequent symptom

  • crieteria for major depression same as with depression in patients with bipolar

  • may not remember/embarressed re manic episodes

• suspect bipolar:

  • family history or “manic depression”

  • probelms with EtOH

  • desplayed risk-taking behaviour in the past

  • history of complicated and disrupted circumstances

    • multiple relationships

    • switching jobs frequently

    • frequent change of address

• compared to Major depression during depressive episode:

  • more likley to have :

    • racing thoughts

    • irritability

  • more likely to have suicidal thoughts

Mania

• full manic episode

  • distinct period of abnormally and persistently elevated or irrable mood

  • abnormal and persistently increase amount of goal directed activity or energy

  • during episode

    • develop grandiose plans

    • multiple overlapping and complex projects

  • decreased need for sleep

• hypomania

  • epsiode less severe

  • doens’t cause same degree of social or ocupational impairment

  • feel very positive, highly productive, function well

  • people close will have noted uncharacteristic mood swing

  • ususally last shorter compared to mania

DSM V - mania

sustained abnormal mood + 3 (or 4 if irritable)

• inflated sef esteem or grandiosity

• increase talkativeness

• decrease need for sleep

• easily distracted by unimportant or ext. irrelevant stimuli

• flight of ideas

• nearly continuous flow of accelerated speech

• abruptly shift 1 topic to another

• increase in goal directed activity

• excessive invomveent in high-risk activities

Types

• Bipolar 1

  • 1 episode of mania

  • many people will be able to function fully between episodes

  • 30% affected reported to be severely impaired at work

    • reduced SES

    • especially repeat episodes

  • M = F

• Bipolar 2

  • at least 1 episode of depression

  • 1 episode of hypomania

    • never full mania

  • mid 20s onset

  • F > M

    • F more likely to seek treatment

• Cyclothymic disorder

  • numerous subsyndromal hypomanic episodes

  • numerous depressive epsidoes

  • neither meet DSMV for either mania or depression

  • will progress to B1 or B2 in 15-50%

• Rapid cycling

  • 4 or more mood disorders within 1 year

  • associated with poor outcomes and reduced response to treatment

  • can be induced by susbstance use and antidepressant monotherapy

management

• led by a psychiatrist

• reduce liklehood of mood swings

  • maintinng daily routines

    • regular medicine

    • healthy sleep patterns

    • exercise

    • avoid etoh

• pharmacological

  • lithium

  • valproate

    • baseline ix

      • fhc, lft, electorlyte, cr

    • ongoing

      • weight, fbc, lft q3mo for 1 yr then annually

    • not used during pregnancy

    • reduce BMD

  • carbamazepine

    • fbc after 1st month of treatment then q6mo

    • measure LFTs, EUC,mohtly for 3mo then q3mo, then q1yr

    • effective contraception

  • lamotrigine

    • emergency medical attention if a rash develops

      • maculopapular and occurs first 8 weeks of treatment

    • effective contraception

  • Atypical antipsychotics

    • identify any family hisotry of long QT

    • weight

    • BP, HbA1c,

• treatment of mania

  • detect early

  • reduce stimulants

  • sleep = important treatment

  • lithium = effective in treating patients during a manic episode

    • + antipsychotic episodes

    • 6-10d to take effects

  • valproate = more rapid response

  • haloperidol effive at controlling acute mania

    • doesn’t prevent depression

    • increase risk of extrapyramidal adverse effects

  • 1/2 respond to monotherapy with either lithium, valproate or an atypical antipsychotic

  • 3/4 likely to respond to combination of either lithium or valproate with an atypical antipsychotic

  • ECT may be useful

• treatment of depression

  • lithium, valproate, lamotrigine = mood stabilisation

    • allow safe use of antidepressant

      • SSRI preferred

• treatment during euthymia

  consider:

  • are symptoms under control

  • has been anychange in circumstances

  • has overall health of patient changed

  • contraception

    • folaic acid

  • monitor for other forms of mental illness

    • expected to develop more than one

Monitoring safe use of lithium

• slow onset of actioin

  • 6-10d mania

  • 6-8wk bipolar depression

• bioavailability differs depending on preparation/formulation

• narrow therapeutic index

• concentration measured 5-7d after dose initiaiton/change

  • 12 hours after dosing

  • 0.6-0.8

    • 0.8-1 recommended for acute episdoes of mania

• measured weekly until stable level achieved

• then q6mo

• advese effects:

  • fine tremor and nausea

    • dose dependent - often pass 1-2d

• toxicity

  • coarse tremor

  • fatigue

  • vomiting/diarrhoea

  • metallic tast

  • reduction in sensitivity of abdomen

• reduces ability to concentrate urine

  • polyuria

  • thirst

  • 10% develop this reversible diabetes insipidus

• weight gain - 10kg

• hypothyroidism 6x more prevalent

• hypercalcaemia

  • elvated parathyroid concentrations

• doses reduced of period of at least 4wks

  • preferably over 3mo

• interactions

  • reduce renal clearance - increase concentration

    • ACEi/ARB

    • dieuretics

    • NSAIDs

tests:

lithium - weekly until stable then 6mo

EUC, TSH, cr every 6mo

ECG — can cause sick sinus syndrome and prolonged QT

calcium yearly