​Kembara Xtra - Medicine - Bipolar I Disorder

​Kembara Xtra - Medicine - Bipolar I Disorder 
Introduction 
An episodic mood disorder is one that has at least one manic or mixed (mania and depression) episode that significantly impairs a person's ability to function, produces psychosis, and/or necessitates hospitalization; severe depressive episodes are not necessary but frequently occur.
Neither a substance nor a general medical issue are to blame for the symptoms.

Aspects of Geriatrics
It is strongly advised to perform a workup for organic or chemically induced pathology in cases of new onset in elderly individuals (>50 years of age).
Child Safety Considerations
The same set of symptoms that apply to adults are used for diagnosis. To distinguish between diseases with overlapping symptoms that are frequently seen in children, such as oppositional defiant disorder (ODD), disruptive mood dysregulation, and attention deficit hyperactivity disorder (ADHD), it is essential to have a clear understanding of the symptoms.

pregnant women's issues
Avoid divalproex (Depakote) due to high teratogenicity risk. Pregnancy does not lessen risk of mood episodes. Need to weigh risk of fetal and mother exposure to mood episode to that of medicine.
A severe acute episode with psychosis and/or infanticidal thoughts is quite likely to occur postpartum.

Incidence and prevalence in Epidemiology 

average of 25 years, with onset typically occurring between the ages of 15 and 30.
Manic episodes are more prevalent in men than depressive episodes are in women over the course of a lifetime, with a prevalence of 1.0-1.6%.

Pathophysiology and Etiology 
Serotonin, norepinephrine, and dopamine dysregulation; MRI results that reveal anomalies in prefrontal cortical regions, the striatum, and the amygdala that precede the start of sickness.


Genetics: Monozygotic twin concordance is 40–70%; dizygotic concordance is 5%.
50% of people have at least one mental disorder-afflicted parent.
First-degree relatives are 7 times more likely than the general population to develop BP-I.

Genetics, significant life stressors, or substance misuse are risk factors.

Prevention

Relapses can be prevented by treatment adherence and education.

 Substance addiction (60%), ADHD, anxiety disorders (50%), and eating disorders are associated conditions.

The presence of at least one manic or mixed episode (simultaneous mania and depression) is necessary for the diagnosis of BP-I. Although a depressive episode is not required for diagnosis, depression affects 80–90% of those with BP-I.
Manic episode, to DSM-5 standards- A distinct episode of abnormally elevated, expansive, or irritated mood accompanied by a surge in activity or energy that lasts for at least a week (or longer if hospitalization is required).
– Three or more of the "DIG FAST" symptoms must continue and be significantly present during the duration of mood disturbance (four if the mood is simply irritated).
 Able to be distracted
Grandiosity or an inflated sense of self, insomnia, a diminished desire for sleep, or rushing thoughts
Taking risks involves engaging in excessively gratifying activities that carry a high danger of unpleasant repercussions (such as financial or sexual), as well as agitation or an increase in goal-directed activity.
- Mixed specifier: when three or more symptoms of the opposing mood pole are present during the primary mood episode, such as mania with mixed aspects of depression, such as a depressed mood, low self-esteem, and death thoughts.


Presenting History – Collateral data enhances diagnoses and is frequently required for a clear history.
Safety problems in the past, such as suicidal or murderous thoughts?
Safety strategy? Psychosis present? ), physical health (e.g., How many hours of sleep did you get? Changes in weight?
Abuse of drugs?, past experiences (e.g., Talkative? Risky driving? extravagant spending? Charge card debt?
Promiscuity? Additional risk-taking habits? Legal trouble? ), substance use (for example, did the mood swing start before or after the substance use?

Findings from the clinical examination of acute mania
- Speech that is rushed and difficult to interrupt - General look that is disordered or discombobulated, psychomotor agitation, bright attire, and heavy makeup - Mood/affect that is euphoric, irritable, expansive, and labile
- Idea flow (streams of thinking come to the patient at a quick rate), prone to distraction
- Grandiosity, paranoia, and hyperreligiosity in thoughts
- Perceptual abnormalities: Delusions, grandiosity, or paranoia are experienced by 3/4 of manic individuals.
- Homicidal/suicidal ideation: aggressiveness toward oneself or others; mixed-episode suicidal ideation is widespread.
- Poor/impaired insight and judgment.

Patients may have a mix of manic and depressive mental states during mixed episodes.
Differential Diagnosis: Other Psychiatric Considerations: Schizophrenia, Schizoaffective Disorder, Personality Disorders (especially Antisocial, Borderline, Histrionic, and Narcissistic), Hyperactivity Disorder (ADD), Substance-Induced Mood Disorder, Unipolar Depression with Psychotic Features, and ADD
The following medical conditions should be taken into account: multiple sclerosis, AIDS, syphilis, a brain tumor, temporal lobe epilepsy, thyroid problems, and other infections.
Consider ADHD and ODD in children.

Diagnostic and laboratory test interpretation
The Mood Disorder Questionnaire is a self-assessment test for history of mood elevation (therefore supposing a bipolar diagnosis) while the BP-I is a clinical diagnostic (sensitivity 73%, specificity 90%).

Determine whether a depressive episode is present and how severe it is by using the Patient Health Questionnaire-9.

Consider brain imaging (CT, MRI) with initial onset of mania to rule out organic cause (e.g., tumor, infection, or stroke), especially with onset in the elderly and if psychosis is present. Initial Tests (lab, imaging) TSH, CBC, BMP, LFTs, RPR, HIV, ESR; drug/alcohol screen with each presentation; dementia workup if new onset in elderly.
Other/Diagnostic Procedures
If the presentation (hyperreligiosity, hypergraphia) points to temporal lobe epilepsy, consider an EEG.

Management 
Generally Speaking 
Ensure safety. Combine medicine and psychotherapy for depression (such as cognitive-behavioral therapy, social rhythm therapy, or interpersonal therapy)
Regular daily routine, with an emphasis on sleep; abstinence from drugs; avoidance of blue light (screens) in the evening; exercise; and a good food.

Acute mania medication (3), (4)[B]
- Opening line
 Lithium-only treatment
Quetiapine, risperidone/paliperidone, aripiprazole, asenapine, and orcariprazine monotherapy are examples of atypical antipsychotics.
Lithium or divalproex combined with an atypical antipsychotic - Second line
Olanzapine, carbamazepine, lithium and divalproex, lithium or divalproex and olanzapine, ziprasidone, and haloperidol are some of the medications used in electroconvulsive therapy (ECT).

First line: "Acute bipolar I depression"
Lithium; lamotrigine; lurasidone; quetiapine - Second line
Divalproex; cariprazine; adjunctive SSRI/bupropion
Olanzapine* plus fluoxetine* + ECT*Concerns about side effects include weight gain, metabolic syndrome, and extrapyramidal symptoms (EPS), which call for the clinician's attention and close observation.

Mood stabilizers or other psychiatric drugs for treatment. Use distinct classes when combining (e.g., an atypical antipsychotic, an antiseizure drug, or lithium).
- Lithium (generic Lithobid, Eskalith): 600 to 1,200 mg/day divided BID-QID; start at 600 to 900 mg/day divided BID-TID, and titrate according to blood levels. Use with caution if you have renal or heart illness; over time, it can cause diabetes insipidus or thyroid disease. Diuretics and ACE inhibitors should be used with caution since dehydration can cause toxicity (seizures, encephalopathy, and arrhythmias).
Pregnancy involves dangers to the fetus and needs thorough monitoring (Ebstein abnormality). ECG >40 years, TSH, BUN, creatinine, and electrolytes should all be checked at baseline and every six months. Level should be checked 5–7 days after starting the medication or changing the dosage, then every 2–3 weeks, and finally every three months (plasma range: 0.8–1.2 mmol/L).

Anti-convulsants: start with 250 to 500 mg BID-TID and up to 60 mg/kg/day for valproic acid (Depakote, Depakene, generic). Black box warnings: pregnancy Category D (high risk for several major abnormalities) and hepatotoxicity, pancreatitis, thrombocytopenia. Avoid in women of reproductive age. 
Check level 5 days after initiation and dose adjustments; monitor CBC and LFTs at baseline and every 6 months (plasma range: 50 to 125 g/mL).
- Carbamazepine (Equetro, Tegretol, generic): dosage is 100 to 200 mg PO BID, titrated up to the lowest effective dose, then 800 to 1,200 mg/day PO divided BID-QID.
Use with caution if taking a TCA or an MAOI within 14 days of each other. Precautions for renal and heart disorders; aplastic anemia/agranulocytosis risk; enzyme inducer; Category D pregnancy. Check level 4 to 5 days after initiation and dose adjustments; monitor CBC and LFTs at baseline and every 3 to 6 months (plasma range: 4 to 12 g/mL).
- Lamotrigine (Lamictal, generic): dosage: 25 mg/day for 2 weeks, 50 mg/day for 2 weeks, 100 mg/day for 1 week, and finally 150 mg/day. (Note: If used with valproate, use a different dosage.) Titrate carefully (risk of Stevens-Johnson syndrome); use cautiously if you have renal, liver, or heart illness; pregnancy is generally safe but requires constant monitoring
- The dosage for oxcarbazepine (Trileptal) is 300 mg PO QD. max. titrate at 1,800 to 2,400 per day.

Atypical antipsychotics - Side effects: tardive dyskinesia, neuroleptic malignant syndrome (NMS), prolactinemia (except aripiprazole [Abilify]), increased risk of death in elderly people with dementia-related psychosis, growing data on relative safety during pregnancy, watch for metabolic side effects above.
– Check for EPS with the Abnormal Involuntary Movement Scale (AIMS), measure weight (including abdominal circumference) at baseline, at 4, 8, and 12 weeks, and then every 3 to 6 months. Finally, check for orthostatic hypotension 3 to 5 days after beginning or changing the dose.
- Aripiprazole: 15 to 30 mg/day; less likely to have negative effects on metabolism
- Dosage for asenapine: 5–10 mg sublingual BID
- The dosage of cariprazine (Vraylar) is 1.5 to 3.0 mg per day for depression and 3 to 6 mg per day for mood elevation.
Olanzapine (Zyprexa, Zydis, generic): dosing: 5 to 20 mg/day; most likely to produce metabolic adverse effects (weight gain, diabetes); lurasidone (Latuda) dosing: 20 to 60 mg/day
- Paliperidone (Invega) dosage: 6 mg every morning; may cause cardiac arrhythmias and agranulocytosis. Risperidone (Risperdal, Risperdal Consta, generic): dose: 1 to 6 mg/day divided QD-QID; IM preparation available (q2wk) Quetiapine (Seroquel, Seroquel XR, generic): dosing: in mania, 200 to 400 mg BID; in bipolar depression, 50 to 300 mg QHS; XR dosing 50 to 400 mg QHS
- Ziprasidone (Geodon): dosage ranges from 40 to 80 mg BID; less likely to have adverse effects on metabolism. QTc prolongation (>500 ms) has been linked to caution. Think about the baseline ECG.

Avoid serotonin norepinephrine reuptake inhibitors (SNRIs) and TCAs due to the risk of mood swings.


Motives for the Referral

Referring to psychiatry, treatment depends on the doctor's expertise and the patient's stability. Patients gain from a multidisciplinary team that includes a primary care doctor, a psychiatrist, and a therapist.

Further Treatments
Transcranial magnetic stimulation, ketamine infusion, ar/modafinil, sleep deprivation, and levothyroxine bipolar depression are all supported with little amounts of evidence.
 Dark treatment or blue-blocking eyewear for mania. Full spectrum Midday light 10,000 lux for depression

Those behind admission

To be admitted involuntarily, a patient must have a psychiatric diagnosis (such as BP-I) and be a danger to themselves or others, or their mental illness must be preventing them from meeting their fundamental needs (such as food, clothes, and shelter).
Nursing: Alert workers to patients who may be agitated or harmful. Suicidal threats that are recent require ongoing monitoring.

Follow-up Regular check-ins encourage treatment compliance. Regular interaction between the therapist, psychiatrist, and primary care physician.
patient observation
Mood charts are useful for keeping track of symptoms.

Prognosis Episode frequency and intensity are correlated with medication compliance, consistency with therapy, sleep quality, and social support.
Within two years of their initial episode, 40 to 50 percent of patients had another manic episode.
25% to 50% of people attempt suicide, and 15% succeed.
A worse prognosis is linked to substance addiction, unemployment, psychosis, depression, and male gender.