BIPOLAR 

Up and down

Bipolar Disorder is a disorder characterized by cycling between mania and depression. They have high highs and low lows. The pathophysiology is not well understood. But the condition is highly heritable. 90% of patients have a family history of bipolar disorder. 

• Bipolar 1 is more severe. They have a hard time functioning in the real world. Most of the time they’re depressed. Sometimes they have manic episodes lasting for a week or more

• Bipolar 2 is milder. They are often high-functioning -- the hypomanic bouts can give them superhuman bursts of energy and focus! Most of the time they’re mildly depressed. Sometimes they have hypomanic episodes lasting for a few days. 

What is mania?

A state of mind characterized by euphoria and energy. Unfortunately the high it provides isn’t sustainable. Mania requires 3+ of the DIG FAST criteria for at least one week: Distractibility, Indiscretion, Grandiosity, Flight of ideas, Activity increase, Sleep decrease and Talkativeness. On my rotations, I found that the best indicator was the feeling that they didn’t need to sleep for days at a time. There are often elements of psychosis present. Antidepressants (SSRIs, SNRIs) can trigger manic episodes. 

What is hypomania?

Hypomania is a milder version of mania. It requires 3+ of the DIG FAST criteria. They cannot have been hospitalized for their symptoms, and they can’t have any psychosis. 

How is bipolar disorder different from borderline personality disorder?

In bipolar disorder, the mood oscillations last for days. In borderline personality disorder the oscillations last for minutes.

Pathophys?

Nobody knows. But keep the kindling theory in mind. It states that most psych disorders which are episodic tend to get progressively worse over time. For that reason, early treatment is a good call. 

Cyclothymia is the mildest form of bipolar disorder. They oscillate between highs and lows, but never meet criteria for MDD or mania. Like dysthymia, the timeline is a minimum of 2 years.

BIPOLAR DRUGS

The ideal bipolar drug would treat (1) the baseline depression, (2) acute flare ups of mania, as well as (3) make their mood less labile. The only drug that does all three is Lithium. But since Lithium has a lot of side effects, many patients require a different regimen. 

DON’T memorize this graph. Just notice that Lithium is the only drug that does all 3 things.

SIDE EFFECTS

Lithium - NEPHROGENIC diabetes insipidus, nausea, tremors, teratogenic in the 1st trimester (Ebstein's Anomaly, where the atria get big and ventricles get small), hypothyroidism, kidney disease, EKG abnormalities. Lithium has a narrow therapeutic window, and also has a lot of drug-drug interactions, which is a pretty nasty combination. There isn’t an antidote, but thankfully, lithium can be filtered from the blood with dialysis. 

• Things that ↑ Lithium levels - Things that affect the kidneys: NSAIDs, ACE Inhibitors, thiazides, Nephrotoxic drugs (Aminoglycosides)

• Things that ↓ Lithium levels - Caffeine

Quetiapine / Olanzapine - Metabolic syndrome (weight gain)

Valproic Acid - Weight gain, pancreatitis, hepatotoxic, alopecia, agranulocytosis, teratogenic (spina bifida, cleft lip). Not a good option for young women, but used often in males. 

Lamotrigine - Rash → Stevens-Johnson Syndrome → TENS

Carbamazepine (not first-line) - CYP450-3A4 autoinducer, SIADH (hyponatremia), ataxia, diplopia, bone marrow suppression (pancytopenia), Stevens-Johnson, teratogenic (spina bifida, cleft lip), inactivates birth control. Oxcarbazepine - same indications as Carbamazepine, but no autoinduction and fewer side effects

Benzos - Can help cool down mania. Risk of oversedation (especially among elderly). Falling out of favor.