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Flashcards in BPAD 2018 guidelines Deck (41)
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1

Acute mania 1st line (CANMAT BPAD 2018)

Lithium
Quetiapine
Divalproex
Asenapine
Aripiprazole
Paliperidone
Risperidone
Cariprazine
Quetiapine + Li/DVP
Aripirazole +Li/DVP
Risperidone + Li/DVP
Asenapine + Li/DVP

2

Acute mania psychotherapy (CANMAT BPAD 2018)

none

3

Hypomania (BD II)
TX (BPAD CANMAT 2018)

-d/c worsening agents (antidepressants, stimulants)
-suggests Li, DVP, atypical antipsychotic (experts)

4

Acute mania children/adolescents
Tx (CANMAT BPAD 2018)

1st: Li, risperidone, aripiprazole, asenapine, quetiapine
2nd: olanzapine, ziprasidone, quetiapine adjunct
3rd divalproex

5

Acute mania 2nd line Tx (CANMAT BPAD 2018)

olanzapine
carbamazepine
olanzapine + Li/DVP
Li + DVP
ziprasidone
haldol
ECT

6

Acute depression (BD) 1st line(CANMAT BPAD 2018)

quetiapine
lurasidone + Li/DVP
lithium
lamotrigine
lursidone
lamotrigine (adjunct)

7

Acute depression (BD) 2nd line(CANMAT BPAD 2018)

Divalproex
SSRI/buproprion adjunct
ECT
cariprazine
olanzapine-fluoxetine

8

Acute depression psychotherapy (CANMAT BPAD 2018)

1st: none
2nd: CBT, family focused
3rd IPSRT

9

Acute depression BD II(CANMAT BPAD 2018)

1st: quetiapine
2nd: Li, lamotrigine, bupropion adj, ECT, sertraline, venlafaxine

10

Acute depression BD children/adolescents (CANMAT BPAD 2018)

1st: lurasidone
2nd: lithium, lamotrigine
3rd: olanzapine-fluoxetine, quetiapine
*cautious use of antidepressants and only with mood stabilizing medications

11

Young women (childbearing)
(CANMAT BPAD 2018)

-divalproex contraindicated
-lamotrigine, topiramate and carbamazepine interfere with OCP
-risperidone may decrease fertility

12

Women in pregnancy (CANMAT BPAD 2018)

-same basic hierarchy considering FDA recommendations re pregnancy
-Divalproex contraindicated
-Li-- fetal cardiac u/s
-atypical antipsychotics (except clozapine), lamotrigine and antidepressants safe
**monotherapy at lowest effective dose**
adjust for changes in physiology

13

Women post partum (CANMAT BPAD 2018)

-eleveated risk of mania
-benzos, antipsychotics and Li for post-partum mania
-quetiapine for depression
-quetiapine and olanzapine best for breast feeding
-avoid antidepressants as high risk for switch

14

Maintenance BD I- 1st line (CANMAT BPAD 2018)

Lithium
quetiapine
divalproex
lamotrigine
asenapine
quetiapine + Li/DVP
Aripirazole +Li/DVP
Aripiprazole (oral and LAI)

15

Maintenance 2nd line (CANMAT BPAD 2018)

Olanzapine
Risperidone LAI (solo and adjunct)
carbamazepine
paliperidone
lurasidone + Li/DVP
Ziprasidone + LI/DVP

16

Maintenance psychotherapy (CANMAT BPAD 2018)

1st line: psychoeducation
2nd: CBT, family focused
3rd: IPSRT, peer support

17

BD II maintenance (CANMAT BPAD 2018)

1st: quetiapine, Li, Lamotrigine
2nd: venlafaxine
3rd: carbamazepine, divalproex, escitalopram, fluoxetine, other antidepressants, risperidone

18

Children and Adolescents Maintenance (CANMAT BPAD 2018)

1st: aripiprazole, Li, divalproex, risperidone + Li/DVP, lithium + DVP/carbamazapine, lamotrigine adj
2nd line: none
3rd: asenapine, quetiapine, risperidone (oral/LAI), ziprasidone (solo or adj)

19

Older adults acute mania (CANMAT BPAD 2018)

1st: Li or divalproex monotherapy
2nd: quetiapine
3rd: asenapine, aripiprazole, risperidone, carbamazapine
Treatment resistant: ECT or clozapine

20

Acute depression- older adults (CANMAT BPAD 2018)

1st: quetiapine, lurasidone
or Li or lamotrigine (adult evidence)
3rd: divalproex, aripiprazole, carbamazepine
Tx resistant: ECT

21

Maintenance- older (CANMAT BPAD 2018)

Li, lamotrigine, divalproex

22

Agitation- 1st line (CANMAT BPAD 2018)

Aripiprazole IM
Lorazepam Im
Loxapine inhaled
Olanzapine IM

23

Agitation 2nd line (CANMAT BPAD 2018)

Asenapine sl
haloperidol IM
Haldol + midazolam IM
Haldol + promethazine IM
Risperidone ODT
Ziprasidone IM
3rd: Haldol po, Loxapine IM, quetiapine Po, risperidone po

24

Depressive symptoms suggestive of Bipolar depression (CANMAT BPAD 2018)

-hypersomnia and/or increased daytime napping
-hyperphagia and/or increased weight
-other atypical depressive sx like leaden paralysis
-psychomotor retardation
-psychotic features and/or pathological guilt
-lability of mood; irritability; psychomotor agitation; racing thoughts
-early onset of first depression (<25 yo)
-multiple prior episodes (>5)
-positive family hx of bipolar d/o

25

Features suggestive of unipolar depression (CANMAT BPAD 2018)

-initial insomnia/reduced sleep
-appetite and/or weight loss
-normal/increased activity levels
-somatic complaints
-late onset of first depression (>25 yo)
-long duration of current episode (>6 months)
-no family hx of bipolar d/o

26

Rating scales BPAD (CANMAT BPAD 2018)

-mood disorders questionnaire (screening)-- really just screens mania
-also use mood charting when possible
(also Young Mania Rating scale-- but not in guidelines)

27

Suicide risk of attempts in BPAD(CANMAT BPAD 2018)

Suicide attempts:
-female, younger (older has higher lethality), young racial minority, single, divorced, single parents,
-young age of onset, first episodes depression, mixed symptoms, mania assoc with more violent attempts, predominantly depressed,
-occurs most during depressed or mixed episodes, greater number/severity of episodes, rapid cycling, anxiety, atypical features, SI
-comorbidities- SUD, smoking, coffee intake, anxiety, eating d/o, borderline/cluster B PDs, obesity
-family hx of mood disorders, BPAD, suicide
-early life stress, abuse
-interpersonal problems, occupational problems, bereavement, social isolation, sexual dysfunction

28

Risk of completed suicide
(CANMAT BPAD 2018)

-male
-older-- higher ratio of deaths/attempts
-current episode depressed, mixed or manic with psychotic features
-hopeless, psychomotor agitation
-comorbid anxiety
-family hx mood disorders, BPAD, suicide
-prior suicide attempts
-psychosocial stressors in last week

29

Chronic disease model(CANMAT BPAD 2018)

-self management support
-decision support (evidence based care)
-community
-delivery system design (culturally sensitive, team based care, case management for complex pt)
-clinical information systems (communication between providers and with patients)
-health system (QI, coordinated care)

30

Risk for treatment non-adherence(CANMAT BPAD 2018)

-male, younger, low education, single
-poor insight, neg attitude to treatment/meds, fear of side effects, low overall life satisfaction, low cognitive function, lack of disease awareness
-alcohol, cannabis, OCD
-no social activities, work impairment
-young age onset, inpatient, hospital or suicide attempt in last year
-hx of mixed episodes, rapid cycling, psychotic features, greater severity, BPAD I, more episodes
-medication side effects, poor efficacy, antidepressant use, low treatment dose