Day # 50: Review Quiz -> Bipolar Part 2

Today will be our second review quiz for the bipolar disorder theme. Take a few minutes and check your learning.

1) Which of the following regarding the mental status exam in patients with bipolar disorder is not true?

a) Impaired judgement is common in manic patients.

b) Hallucinations occur in ~25% of manic patients.

c) Delusions occur in ~75% of manic patients.

d) Manic patients are among the most likely to be assaultive or threatening.

2) Which form of psychotherapy has robust evidence as an adjunct to mood stabilizers in bipolar disorder?

a) Psychodynamic Psychotherapy

b) Stimulus Control Therapy

c) Written Exposure Therapy

d) Interpersonal and Social Rhythm Therapy

3) What medication is not FDA approved for the treatment of bipolar depression?

a) Quetiapine

b) Aripiprazole

c) Lurasidone

d) Olanzapine + Fluoxetine

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Answers

DON'T LOOK UNTIL YOU HAVE FINISHED THE ENTIRE QUIZ

Question 1:

From day #50:

Answer: b

Hallucinations occur in ~50% (not 25%) of manic patients.

Explanation:

These features are very common in patients with bipolar disorder. 1

• Delusions occur in 75% of all manic patients.

• 51% experience hallucinations.

• 47% had paranoid features.

•Manic (and demented) patients are the most likely patient to be assaultive or threatening. Some studies site that about 75% can have threatening behaviors. They also have a higher rate of suicide and homicide. 2

•Impaired judgement is a hallmark of manic patients. This may lead to sexual indiscretion, excessive gambling or poor financial management, breaking the law, etc.

Question 2:

From day #48:

Answer: d

Interpersonal and Social Rhythm Therapy

Explanation:

Bipolar disorder is characterized by frequent recurrences/relapses. These are often related to:

• Noncompliance with medications

• Stressful life events

• Social rhythm disruption / Circadian rhythm disruption

Interpersonal and social rhythm therapy (IPSRT) was designed to address these problem areas.

Question 3:

From day #49:

Answer: b

Aripiprazole is not FDA approved for bipolar depression

Explanation:

Acute depression

Use of standard antidepressants may induce mania in those with or without diagnosis of bipolar disorder (6–8% of patients with MDD will switch to hypomania/mania). 2 Risk is higher with TCAs and younger patients. For this reason we typically avoid antidepressants with the exception of the approved combination of olanzapine + fluoxetine. Treatment options for acute depression include:

• Lithium +/- lamotrigine

• Valproic acid

• Quetiapine (FDA approved for bipolar depression)

• Olanzapine + fluoxetine (FDA approved for bipolar depression)

• Also be sure to, if possible, taper and discontinue medications known to contribute to depression in these patients to include steroids, beta blockers, varenicline, statins, OCPs, hormone replacement, etc...

• Second line options include Lurasidone (FDA approved for bipolar depression) or ECT. Controversial use of SSRIs, SNRIs, MAOIs, and TCAs.

"Breakthrough" depression

• Ensure levels of medication are therapeutic (Ex: Lithium or Valproate).

• Add second generation antipsychotic such as olanzapine or quetiapine.

• Consider ECT if refractory.

CONCLUSION

Nice work. Definitely review these posts if you had a hard time answering. If you want to see all of the weekly quizzes you can see them here. Next lesson we will discuss bipolar depression in more detail before diving into the details of mood stabilizers.