Bipolar Disorder - Psychiatry - Medbullets Step 2/3

Snapshot

A 25-year-old male is brought into the emergency room by his family when he spent over $100,000 on building supplies and was found naked in his back yard building a boat so he can sail the world to teach English to the people of England. His family and friends said that for the last 2 weeks he had been increasingly grandiose, had been sleeping 3 hours per night, and had not gone to work. Prior to this episode, the patient had been relatively normal, however, he had experienced a bout of depression 12 months ago. The patient's speech seems pressured as he began to explain his idea to solve world homelessness with his program "Hammocks for the Homeless." The patient's wife further offers that he has had a significantly increased sexual drive lately. His urine tox screen was negative in the ED.

Introduction

Epidemiology
- seen in 1% of population
- genders equally affected
- often presents in young people (most common onset between 20-30 years)
Subtypes
- bipolar I
  - manic episode with or without major depressive episodes
- bipolar II
  - hypomanic episodes with at least one major depressive episode
- rapid cycling
  - > 4 episodes of mania/depression/mixed within 1 year
- cyclothymic
  - alternating hypomanic episodes with dysthymia
    - psychotherapy is best initial step in management
    - some evidence suggests valproic acid is better than lithium for these patients

Presentation

Symptoms
- manic symptoms
  - DIG FAST
    - Distractibility
    - Insomnia
    - Grandiosity
    - Flight of Ideas
    - Agitation
    - Sexual indiscretions/pleasurable activities
    - Talking (pressured speech)
- hypomanic symptoms
  - similar but does not lead to marked impairment
  - no psychotic symptoms present
  - impulsivity is present

Evaluation

Diagnosis
- episodes should last > 1 week and be continous
- must rule out cocaine or amphetamine use
  - always do a urine toxicology for patients presenting with mania

Treatment
Lithium first-line mood stabilizer (can take 1 week to work) check creatinine before initiating therapy renal failure, hyponatremia, and dehydration all increase likelihood of lithium toxicities can cause hypothyroidism, and Epstein's anomaly in pregnant patients shown to have a reduction in mortality from suicide Hospitalization often involuntary as manic patients do not recognize their illness Benzodiazepines may assist in acute sedation if patient is agitated Antiepileptics valproate (useful for patients with renal dysfunction) or carbamazepine second line mood stabilizers atypical antipsychotics can also be used (risperidone can be first-line) may begin antidepressant therapy only after mood stabilizers are started lamotrigine also used (can be first-line) haloperidol used as a first-line of treatment in pregnant patients with acute mania first-line in acute mania in patients with severe symptoms Atypical antipsychotics or antipsychotics quetiapine or olanzapine can be used as second line side effects of weight gain, thus often avoided in obese patients haloperidol can be used first line in pregnant patients SSRI's can induce mania (e.g., if started in patients misdiagnosed with major depressive disorder)
Prognosis, Prevention, and Complications
Prognosis worse than major depression high prevalence of alcohol/substance abuse high risk of suicide - worst during a mixed episode lithium is the only drug shown to reduce mortality from suicide (2015) Prevention if less than 3 lifetime relapses, it is possible to treat for 1 year followed by a mood stablizer taper if 3 or greater lifetime relapses, it is necessary to remain on lifetime mood stabilizer treatment

Blood, Plasma, Serum	Reference Range
ALT	8-20 U/L
Amylase, serum	25-125 U/L
AST	8-20 U/L
Bilirubin, serum (adult) Total // Direct	0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca²⁺)	8.4-10.2 mg/dL
Cholesterol, serum	Rec: < 200 mg/dL
Cortisol, serum	0800 h: 5-23 μg/dL //1600 h: 3-15 μg/dL 2000 h: ≤ 50% of 0800 h
Creatine kinase, serum	Male: 25-90 U/L Female: 10-70 U/L
Creatinine, serum	0.6-1.2 mg/dL
Electrolytes, serum
Sodium (Na⁺)	136-145 mEq/L
Chloride (Cl^-)	95-105 mEq/L
Potassium (K⁺)	3.5-5.0 mEq/L
Bicarbonate (HCO₃^-)	22-28 mEq/L
Magnesium (Mg²⁺)	1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)
24-28 wks // 32-36 wks	30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks	40-220 ng/mL // 80-350 ng/mL
Ferritin, serum	Male: 15-200 ng/mL Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma	Male: 4-25 mIU/mL Female: premenopause: 4-30 mIU/mL midcycle peak: 10-90 mIU/mL postmenopause: 40-250
pH	7.35-7.45
PCO₂	33-45 mmHg
PO₂	75-105 mmHg
Glucose, serum	Fasting: 70-110 mg/dL 2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation	Fasting: <5 ng/mL Provocative stimuli: > 7ng/mL
Immunoglobulins, serum
IgA	76-390 mg/dL
IgE	0-380 IU/mL
IgG	650-1500 mg/dL
IgM	40-345 mg/dL
Iron	50-170 μg/dL
Lactate dehydrogenase, serum	45-90 U/L
Luteinizing hormone, serum/plasma	Male: 6-23 mIU/mL Female: follicular phase: 5-30 mIU/mL midcycle: 75-150 mIU/mL postmenopause 30-200 mIU/mL
Osmolality, serum	275-295 mOsmol/kd H₂O
Parathyroid hormone, serume, N-terminal	230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C)	20-70 U/L
Phosphorus (inorganic), serum	3.0-4.5 mg/dL
Prolactin, serum (hPRL)	< 20 ng/mL
Proteins, serum

Hematologic	Reference Range
Bleeding time	2-7 minutes
Erythrocyte count	Male: 4.3-5.9 million/mm³ Female: 3.5-5.5 million mm³
Erythrocyte sedimentation rate (Westergren)	Male: 0-15 mm/h Female: 0-20 mm/h
Hematocrit	Male: 41%-53% Female: 36%-46%
Hemoglobin A1c	≤ 6 %
Hemoglobin, blood	Male: 13.5-17.5 g/dL Female: 12.0-16.0 g/dL
Hemoglobin, plasma	1-4 mg/dL
Leukocyte count and differential
Leukocyte count	4,500-11,000/mm³
Segmented neutrophils	54%-62%
Bands	3%-5%
Eosinophils	1%-3%
Basophils	0%-0.75%
Lymphocytes	25%-33%
Monocytes	3%-7%
Mean corpuscular hemoglobin	25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration	31%-36% Hb/cell
Mean corpuscular volume	80-100 μm³
Partial thromboplastin time (activated)	25-40 seconds
Platelet count	150,000-400,000/mm³
Prothrombin time	11-15 seconds
Reticulocyte count	0.5%-1.5% of red cells
Thrombin time	< 2 seconds deviation from control
Volume
Plasma	Male: 25-43 mL/kg Female: 28-45 mL/kg
Red cell	Male: 20-36 mL/kg Female: 19-31 mL/kg

Cerebrospinal Fluid	Reference Range
Cell count	0-5/mm³
Chloride	118-132 mEq/L
Gamma globulin	3%-12% total proteins
Glucose	40-70 mg/dL
Pressure	70-180 mm H₂O
Proteins, total	< 40 mg/dL

Sweat	Reference Range
Chloride	0-35 mmol/L
Urine
Calcium	100-300 mg/24 h
Chloride	Varies with intake
Creatinine clearance	Male: 97-137 mL/min Female: 88-128 mL/min
Estriol, total (in pregnancy)
30 wks	6-18 mg/24 h
35 wks	9-28 mg/24 h
40 wks	13-42 mg/24 h
17-Hydroxycorticosteroids	Male: 3.0-10.0 mg/24 h Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total	Male: 8-20 mg/24 h Female: 6-15 mg/24 h
Osmolality	50-1400 mOsmol/kg H₂O
Oxalate	8-40 μg/mL
Potassium	Varies with diet
Proteins, total	< 150 mg/24 h
Sodium	Varies with diet
Uric acid	Varies with diet
Body Mass Index (BMI)	Adult: 19-25 kg/m²