Bipolar Disorders

Nursing 256: Psychiatric Nursing

Kristina Hansen, MN, ARNP, FNP-BC, CCRN-K
 Epidemiology

• Bipolar disorder affects approximately 4.4% of American adults and

82.9% of these cases are considered severe.
• Gender incidence is roughly equal.
• Bipolar disorder is associated with increased mortality in general and
particularly with death by suicide
• Average age at onset is 25 years.
• Occurs more often in the higher socioeconomic classes
• Sixth-leading cause of disability in the middle-age group
• Bipolar disorder is the sixth-leading cause of disability in the middle-
age group, but for those who respond to lithium treatment (about
33% of those treated with lithium), bipolar disorder may be
completely treatable, with no further episodes. Unfortunately, many
individuals go for years without an accurate diagnosis or treatment,
and for some the consequences can be devastating.
 Introduction- Terms to know
• Mood is defined as a pervasive and sustained emotion that may have a major
influence on a person’s perception of the world.
• Examples of mood: Depression, joy, elation, anger, anxiety
• Affect is described as the emotional reaction associated with an experience.
• Mania is an abnormally elevated mood, which can also be described as
expansive or irritable, feelings of elation, inflated self-esteem, grandiosity,
hyperactivity, agitation, and accelerated thinking and speaking. Manic episodes
last at least 1 week. Mania can occur as a biological (organic) or psychological
disorder, or as a response to substance use or a general medical condition.
• Hypomania: A less severe episode of mania that lasts for at least 4 days
but less than 7 accompanied by 3 or more manifestations of mania.
Hospitalization is not required, and the client is less impaired. May
progress to mania.
• Rapid cycling: Four or more episodes of hypomania or acute mania
within 1 year and associated with increase recurrence rate and resistance
to treatment.
 Bipolar Disorder

•Etiology- Exact cause is unknown

•Bipolar disorders are mood disorders with recurrent episodes of depression and
mania.
•Mood swings from profound depression to extreme euphoria (mania)
•Periods of normal functioning alternate with periods of illness, though some clients
are not able to maintain full occupational and social functioning.
•Clients can exhibit psychotic, paranoid, and/or bizarre behavior during periods of
mania.
 Types of Bipolar
Disorders
• Bipolar I disorder
• Client is experiencing, or has
experienced, a full syndrome
of manic or mixed symptoms.
• May also have experienced
episodes of depression
• Psychosis
• Impairs functioning and
socialization
• Hospitalization often
required to stabilize.
Bipolar II disorder

• Characterized by
one or more
hypomanic
episodes
alternating with
major depression
episodes.
• Has never met
criteria for full
manic episode
• No psychosis
• Cyclothymic
Disorder
• Cyclothymic disorder is a
chronic mood disturbance
of at least 2 years,
involving numerous
periods of elevated mood
that do not meet the
criteria for a hypomanic
episode, and numerous
periods of depressed
mood of insufficient
severity or duration to
meet the criteria for a
major depressive episode.
The individual is never
without the symptoms for
more than 2 months.
 • Substance- and • Bipolar disorder due to
Other medication-induced another medical
bipolar disorder condition
types of • A disturbance of • Characterized by
Bipolar mood (depression or
mania) that is
an abnormally and
persistently
considered to be the elevated,
Disorders direct result of the expansive, or
physiological effects irritable mood and
of a substance (for excessive activity
example, ingestion or energy that is
of or withdrawal judged to be the
from a drug of abuse result of direct
or a medication or physiological
other treatment) effects of another
medical condition
 RISK FACTORS FOR
BIPOLAR DISORDER
• The exact etiology of bipolar disorder has yet to be
determined. Scientific evidence supports a chemical
imbalance in the brain. Theories that consider a
combination of hereditary factors and environmental
triggers seem to be the most credible.

• Genetics: Family history is the strongest and most

consistent risk factor.
• Biochemical influences
• Possible excess of norepinephrine and dopamine
• Physiological influences (Neurobiological and
Neuroendocrine disorders)
• Brain lesions
• Enlarged ventricles
• Medication side effects

• Environmental: Increased stress in the environment

can trigger mania and depression and increase risk for
severe manifestations in genetically-susceptible
children. Drug or alcohol abuse.
• Co-occurring conditions: anxiety, eating disorders,
ADHD, other health conditions
 STAGES OF MANIA: Symptoms may be
categorized by degree of severity.
Stage I. Hypomania: Symptoms not sufficiently severe
to cause marked impairment in social or occupational
functioning or to require hospitalization
Cheerful mood
Rapid flow of ideas; heightened perception
Increased motor activity
Stage II. Acute mania: Marked impairment in
functioning; usually requires hospitalization
Elation and euphoria; a continuous “high”
Flight of ideas; accelerated, pressured speech
Hallucinations and delusions
Excessive motor activity
Social and sexual inhibition
Little need for sleep
Stage III. Delirious mania: A grave form of the disorder
characterized by an intensification of the symptoms
associated with acute mania. The condition is rare
since the advent of antipsychotic medication.
Labile mood; panic anxiety
Clouding of consciousness; disorientation
Frenzied psychomotor activity
Exhaustion and possibly death without
intervention
 PATIENT CENTERED CARE –
ACUTE MANIA
FOCUS IS ON SAFETY AND MAINTAINING PHYSICAL HEALTH

Therapeutic Milieu (within acute care medical facility)

• Provide a safe environment during the acute phase
• Assess the client regularly for suicidal thoughts, intentions, and escalating behavior
• Decrease stimulation without isolating the client if possible. Be aware of noise, music, television, and
other clients, all of which can lead to an escalation of the client’s behavior. In certain cases, seclusion
might be the only way to safely decrease stimulation for the client .

• Follow facility/agency protocols for providing client protection (restraints, seclusion, one to one
observation) if a threat of self injury to others exists

Communication
• Use a calm, matter of fact specific approach
• Give concise explanations
• Provide for consistency with expectations and limit setting
• Avoid power struggles, and do not react personally to the client’s comments
• Reinforce nonmanipulative behaviors
• Use therapeutic communication techniques

Maintenance of Self Care Needs

• Monitoring sleep, fluid intake and nutrition
 POTENTIAL
COMPLICATIONS

Physical Exhaustion and possible death:

A client in a true manic state usually will
not stop moving, and does not eat,
drink or sleep. This can become a
medical emergency.

Nursing Actions
• Prevent client self harm
• Decrease client’s physical activity
• Ensure adequate fluid and food intake
• Promote adequate amount of sleep
each night
• Assist with client with self care needs
• Manage medication(s) appropriately
 Psychopharmacology

• TREATMENT OF ACUTE MANIA – Mood

Stabilizers
• Lithium carbonate
• Anticonvulsants that act as mood
stabilizers: Valproate and Carbamazepine
• First Generation Antipsychotic medications:
• Chlorpromazine and loxapine

• Second Generation Antipsychotics

• Olanzapine, risperidone etc.
• Lurasidone and quetiapine are approved to treat
depression and Bipolar

• TREATMENT OF DEPRESSIVE PHASE

• Fluoxetine (Use antidepressants with
caution as they may trigger mania if not
combined with a mood stabilizer).
Lithium
Narrow Therapeutic window:
0.5mEq/L – 1.2mEq/L

• FDA approved for the treatment of Manic episodes and maintenance

treatment of manic depressive patients with history of mania. Shown
to reduce incidence of suicide with Bipolar six or seven fold.
• Off Label usage: Bipolar depression, Major Depression
• Excreted by the kidneys
• Drug interactions with Lithium
• NSAIDs – may reduce lithium clearance and increase serum concentration
• Thiazide diuretics- reduced renal clearance and increased serum
concentration
• ACE Inhibitors- reduced lithium clearance, increase concentrations and
toxicity
• Metronidazole- increased lithium concentration
Lithium Adverse Effects

• Neurological – Tremor, slowed reaction time, memory difficulties

• TOXIC: ataxia, course tremor, neuromuscular irritabilities, seizures,
come and death
• Endocrine: Goiter, hypothyroidism, hyperthyroidism (rare)
• Cardiac: Benign T wave changes
• Renal: Morphologic changes, polyuria, reduced GFR
• Dermatological: Acne, hair loss, psoriasis, rash
• GI: N/V/D, appetite loss
• Other: weight gain, fluid retention
 Tests:
• Before initiating – kidney function, TSH, EKG in
those > 50 y/o
• Monitoring: Kidney function 1-2x per year;
frequent trough levels; monitor for metabolic
syndrome (BMI, weight, lipids & HbA1c)
Client/
Family Patient Education:
Education on
Lithium • Last dose of lithium should be aprox 12
hours before lab draw
• Avoid sudden changes in diet or fluid intake
• Caffeine and alcohol acts as diuretics which
can lower serum concentrations
• Changes in exercise (more vigorous) may
affect lithium levels
• Take the medication regularly.
• Drink six to eight glasses of water each day.
• Notify HCP if vomiting or diarrhea occur.
 Signs & Symptoms
of Lithium Toxicity
• Mild to moderate (1.5 – 2.0 mEq/L)
• Vomiting, abdominal pain
• Ataxia, dizziness, slurred speech,
nystagmus, muscle weakness
• Moderate to Severe (2.0 –
2.5mEq/L)
• Anorexia, persistent N/V
• Blurred vision, clonic limb
movements, hyperactive deep tendon
reflexes, convulsions, delirium, coma
and stupor
• Severe > 2.5mEq/L
• Convulsions, oliguria and renal failure
and possible DEATH
• May require hemodialysis
Management of Lithium
Toxicity
• Contact provider or go to the
nearest ER
• DISCONTINUE LITHIUM
• Vital signs and neurological exam
• Draw lithium levels, serum
electrolytes, renal tests, and EKG
• Emesis, gastric lavage, and
absorption with activated
charcoal
• For any patients with lithium
level greater than 4.0mEq/L will
require hemodialysis
Valproic Acid (Depakote)
Therapeutic index: 50-100 mcg/mL
• Valproate/Depakote
• FDA approved for the tx of mania and mixed episodes
• Preferred tx for rapid cycling (x4/year)
• Adverse Effects:
• Common: GI irritation, Nausea, sedation, tremor, weight gain , hair loss
• Uncommon: V/D, ataxia, persistent elevated hepatic transaminase (liver
function)
• RARE: Platelet dysfunction, agranulocytosis, edema

Monitoring: Prior to starting: Baseline hepatic panel, CBC with platelet count,
and pregnancy tests
Recurrent- LFTs, VPA level, platelets the first few months of tx

* Monitor for metabolic syndrome*

Lamotrigine (Lamictal)

• FDA approved for the maintenance of Bipolar I

• OFF Label usage: Bipolar Depression, Bipolar Mania, Neuropathic
pain/chronic pain & Major Depression (Adjunct)
• Adverse Effects: Dizziness, Ataxia, Somnolence, Headaches, Blurred
vision, Nausea, **Rash- common and occasionally very severe. Drug
should be d/c if a rash develops as it could manifest to Steven
Johnsons syndrome*
Drug-Drug interactions:
• Concurrent Depakote doubles Lamictal serum concentrations
• Food does not affect absorption
CARBAMAZEPINE (Tegretol)
4-12 mcg/mL
• OFF Label used for the treatment of Bipolar depression, Bipolar
Maintenance, Psychosis, Adjunct treatment of Schizophrenia
• Food enhances absorption
• Metabolized by the liver
• Decreases blood concentrations of oral contraceptives; resulting in
breakthrough bleeding and uncertain prophylaxis against pregnancy
• Should not be administered with MAOIs and they should be d/c 2
weeks before starting Tegretol
 Treatment
Modalities for
Bipolar Disorder

• Individual psychotherapy

• Group therapy

• Family therapy

• Cognitive therapy

• The Recovery Model

• Learning how to live a safe, dignified, full, and
self-determined life

• Continuous recovery process

• Goals, treatment plan, strategies for success

• Clinician, nurses provide support

 • Electroconvulsive therapy (ECT)
Episodes of acute mania are
occasionally treated with
electroconvulsive therapy
THERAPEU particularly when:

TIC • Client does not tolerate

medication.
PROCEDUR
ES • Client fails to respond to
medication.

• Client’s life is threatened by

dangerous behavior
or exhaustion.
Client/ • Nature of the illness
Family • Management of the illness
Education • Crisis hotline & Support services