​Kembara Xtra - Medicine - Bipolar II Disorder

​Kembara Xtra - Medicine - Bipolar II Disorder 

Introduction 

A mood illness that includes at least one major depressive episode (with or without psychosis) and at least one episode of hypomania, a mild mood elevation
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 assess risk of exposure to mood episode versus that of medicine.
A severe acute episode with psychosis and/or infanticidal thoughts is quite likely to occur postpartum.

Prevalence and incidence of disease 
typically begins between the ages of 15 and 30
0.5% to 1.0% lifetime incidence; more prevalent in women

Pathophysiology 
biogenic amines or neurotransmitters that are dysregulated, including serotonin, norepinephrine, and dopamine
Genetics
Estimated heritability: >77%

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

Prevention
Continued treatment and education can help stop new occurrences.

Accompanying Conditions 

ADHD, substance abuse, anxiety issues, and eating disorders 

One hypomanic episode and at least one major depressive episode are required for the DSM-5 diagnosis. Mood elevation symptoms generate clear changes in functioning that are observed by others but are not severe enough to significantly hinder functioning.
Hypomania is a distinct time of persistently elevated, expansive, or irritated mood that lasts at least four days and differs from the typical euthymic mood: – At least three of the "DIG FAST" symptoms must be present, together with the additional signs of increased energy listed below (four if the mood is just irritable): ○ Distractibility
 Insomnia and a diminished desire to sleep
Grandiosity or an exaggerated sense of self-worth; a flurry of ideas or racing thoughts
 An increase in agitation or goal-directed activity (sexually, at work or school)  Talkative/pressured speech compared to typical
danger-taking is the excessive engagement in pleasurable activities that carry a high danger of unpleasant outcomes (such as sexual or financial). 
Major depression is defined as having a depressed mood or decreased interest as well as four or more of the "SIG E CAPS" symptoms all occurring during a 2-week period. - Sleep disturbance, such as difficulty falling asleep or waking up early - Interest: anhedonia or loss
- Guilt (or a sense of insignificance)
- Energy and loss
- Dizziness, loss of
Psychomotor alterations (retardation or agitation), including changes in appetite.
- Suicidal or murderous thoughts
- Rapid cycling involves four major depressive episodes or one episode of hypomania in a 12-month period.
When three or more symptoms from the opposite mood pole are present during the primary mood episode, for example, hypomania with mixed features (of depression), the diagnosis is BP-I. However, if symptoms have ever met the criteria for a full manic episode, such as when hospitalization was required as a result of manic/mixed symptoms or when psychosis was present, the diagnosis is BP-I.

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? Substance abuse? ), and past experiences (risky driving? extravagant spending?
Charge card debt? Promiscuity? Additional risk-taking habits?
Legal trouble?, substance use (for example, did the mood swing start or end with substance use) 

clinical assessment and conclusions 

Examining the mental state in hypomania - Appearance in general: usually appropriately attired, often with psychomotor excitement and vivid colors. Speech that may be rushed, chatty, or difficult to interrupt. Mood or attitude that may be expansive, congruent, euphoric, or irritable. - Thought process: prone to distraction, trouble focusing on one thing at a time - Thought content: often optimistic, with "big" goals
- No perceptual deviations
Low incidence of homicidal or suicidal ideas; insight and judgment are often stable but can be affected by grandiosity or distraction.
Examining the mental state in depression - Unkempt appearance, poor eye contact, and psychomotor impairment - Low, quiet, monotonous voice
- Sad, depressed/congruent, flat mood/effect
- Thought process: generalized slowness, pondering thoughts - Mental attitude: concerned with pessimistic or nihilistic notions - Perceptual abnormalities: Hallucinations or delusions are experienced by 15% of depressed people.
- Suicidal and homicidal thoughts: Suicidal thoughts are extremely common.
- Impaired insight and judgment frequently

Other psychiatric factors to be taken into account when making a differential diagnosis include BP-I disorder, unipolar depression, personality disorders (especially borderline, antisocial, and narcissistic disorders), ADHD, and substance-induced mood disorder. 
Medical conditions to take into account include multiple sclerosis, autoimmune diseases, AIDS, syphilis, temporal lobe epilepsy, brain tumors, infections, strokes, and endocrine conditions like thyroid illness. 

Analysis of a diagnostic test 
Mood Disorder Questionnaire, self-assessment screen for history of mood elevation (therefore presuming bipolar diagnosis) BP-II is a clinical diagnostic.

With a sensitivity of 80% and a specificity of 51%, the Hypomania Checklist-32 can distinguish between BP-II and unipolar depression.
The Patient Health Questionnaire-9 can assist identify whether depression is present and how severe it is.

Initial examinations (lab, imaging)
During the initial episode, rule out organic causes of mood disorders.
Every presentation should include a drug and alcohol screening.
If dementia in an elderly person develops suddenly, be tested 
Consider CBC, Chem 7, TSH, LFTs, ANA, RPR, HIV, and ESR with initial presentation.
Consider brain imaging (CT, MRI) to rule out organic causes when hypomania first manifests, especially in elderly patients.

Management and Therapy 
Ensure safety. Treat depression with medicine and psychotherapy (such as CBT, social rhythm, interpersonal, or family oriented). Maintain a regular circadian rhythm/daily sleep and activity schedule, exercise, and a nutritious diet.

Acute mood elevation caused by medication - first line
Atypical, other: cariprazine, risperidone, aripiprazole, ziprasidone, asenapine Quetiapine, lithium Atypical, other: Divalproex (avoid in reproductive age women) - Second line
Haloperidol, paliperidone, atypical plus lithium, atypical plus divalproex, or lithium plus divalproex
First line: "Acute bipolar II depression"
Second line: Quetiapine
 Cariprazine, lithium, lamotrigine, lurasidone,
ECT as a bupropion adjunct

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; it can cause diabetes insipidus or thyroid problems. Diuretics and ACE inhibitors should be used with caution since dehydration can cause toxicity (seizures, encephalopathy, and arrhythmias).
Pregnancy necessitates close observation. Monitor: ECG over 40, TSH, BUN, creatine, and electrolytes should all be checked at baseline and every six months. Check level five to seven days following start-up or dose change, then every two to three weeks, and finally every three months (target: 0.8 to 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). Hepatotoxicity, pancreatitis, thrombocytopenia, and pregnancy Category D black box warnings. Check level 5 days after dosage initiation and dose adjustments; monitor CBC and LFTs at baseline and every 6 months (target: 50 to 125 g/mL).
Lamotrigine (generic Lamictal): 200 to 400 mg/day; start at 25 mg/day for two weeks, move up to 50 mg/day for two weeks, then 100 mg/day for one week, and finally 150 mg/day. (Note: If using with valproate, use half the recommended dose.) Pregnancy Category C - Atypical antipsychotics Warning: Titrate gently (risk of Stevens- Johnson syndrome); use caution with renal, liver, or heart illness
 Adverse reactions: prolactinemia (apart from aripiprazole), tardive dyskinesia, neuroleptic malignant syndrome (NMS), metabolic side effects (glucose and lipid dysregulation, weight gain), increased risk of death in elderly with dementia-related psychosis, pregnancy Category C
Check for EPS with the Abnormal Involuntary Movement Scale (AIMS), measure weight (with abdominal circumference) at baseline, at 4, 8, and 12 weeks, and then every 3 to 6 months. Check for orthostatic hypotension 3 to 5 days after starting or changing the dose.
 Aripiprazole (Abilify): 10 to 30 mg/day dosage; less likely to result in adverse metabolic consequences than other AAPs.
Asenapine dosage: sublingual 5–10 mg BID
The dosage for cariprazine (Vraylar) is 1.5 to 3 mg for depression and up to 6 mg for mood elevation.
 Lurasidone (Latuda) dosage: 20 to 60 mg/day; less likely to have adverse effects on metabolism 
Paliperidone (Invega) dosage: 6 mg in the morning; potential side effects include agranulocytosis and cardiac arrhythmias 
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 600 mg QHS; XR dosing 50 to 400 mg QHS 
Ziprasidone (Geodon) dosage: 40 to 80 mg BID; less likely to have adverse effects on metabolism. Attention: Use has been linked to QTc prolongation (>500 ms) (0.06%). Think about the baseline ECG.

Bupropion (Wellbutrin), a unipolar antidepressant, is dosed at 150 to 300 mg PO daily. Use only with an antimanic medication.
– Avoid serotonin-norepinephrine reuptake inhibitors and TCAs since they increase the risk of mood swings.
QUESTIONS FOR REFERENCE
Referral to psychiatry is advised; this relies on the doctor's level of expertise and the patient's level of stability.
Patients gain from working with a multidisciplinary team that consists of a primary care doctor, a psychiatrist, and a therapist.

Further Treatments
There is some evidence that bipolar depression can be treated with transcranial magnetic stimulation, vagus nerve stimulation, ketamine infusion, sleep restriction, and hormone therapy (such as thyroid).
Blue-blocking eyewear or dark therapy to improve mood

Motivation for 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 and clothes).
Nursing: Alert workers to patients who may be agitated or harmful. Suicidal threats that are recent require ongoing monitoring.

Take Action
Regular check-ins encourage treatment compliance.
Mood charts are useful for patient monitoring of symptoms.


Prognosis Episode frequency and intensity are correlated with medication compliance, consistency with therapy, sleep quality, and social support.
25% to 50% of people attempt suicide, and 15% succeed.
A worse prognosis is linked to substance addiction, unemployment, psychosis, depression, and male gender.