Unit 1 - Bipolar Disorder and Medications

Bipolar Disorder + Key Features

• Brain disorders characterized by shifts in…

  • mood

  • energy

  • activity levels

  • ability to carry out day-to-day tasks

• Moods range from periods of extremely “up,” elated, & energized behavior (manic episodes) and range down to very sad or hopeless periods (depressive episodes)

Mania

Characterized by unusually high disruptive mood elation, expansive, and irritability lasting often for days

• Interferes with work and daily function

• Marked with delusional thinking and sometimes hallucinations

• Full blown mania means there is an episode of mania with psychosis (loss of reality)

  • Delusions (false beliefs)

  • Hallucinations (false sensory perceptions)

  • Severe impairment in social & occupational functioning

Hypomania

Manic symptoms are less severe and do not result in marked social or occupational impairment

• hospitalization is not required at this stage

Symptoms of Mania

• Euphoric/expansive mood

• Grandiosity (inflated self-esteem)

• Decreased need for sleep

• Pressured speech

• Racing thoughts; flight of ideas

• Distractibility

• Increase in goal-directed activity (often unrealistic goals)

• Psychomotor agitation

• Excessive involvement in pleasurable or risky activities

Types of Hallucinations

• Visual – seeing a deceased loved one

• Auditory – hearing voice of a deceased loved one

• Tactile – feeling things not really there, such as large spiders crawling on skin

• Olfactory – smelling things not there

• Gustatory – tasting things not there

Types of Delusions

• Nihilistic – A man refuses to eat, saying that there is no need to eat because the world has ended.

• Somatic – A woman believes her body is rotting away; her heart is made of stone, and she doesn’t deserve to live.

• Grandiose - A man believes he is God and rules the universe (someone special).

• Persecutory – A woman believes that staff belong to a cult and is afraid to go to sleep for fear of what staff might do.

Bipolar Type 1

• Experiences mania symptoms with some depressive episodes

• Experiences distinct period of abnormal persistent expansive, irritable or elevated mood lasting at least 1 week with 3 or more symptoms

• Mood/behavior IMPAIRS work, school or life functional status

• Not attributed to substances or medical condition

Bipolar Type 2

• Experiences depression

• Experiences hypomania

  • period of elevation, expansive or irritability in mood lasting 4 days but without expression of mania

• Does not cause impairment of social or work related functioning at it’s severest level

Cyclothymic Disorder

Chronic mood disturbance of 2 years or more with numerous periods of elevated/expansive mood and depressive mood changes without meeting criteria for hypomania episodes or level of depressive periods

How to Assess for Bipolar Disorder:

DIG FAST

• D is for distractibility

• I is for impulsivity

• G is for grandiosity

• F is for flight of ideas

• A is for activity

• S is for sleep

• T is for talking (often excessive and loud & pressured speech)

Drug Classes used for Bipolar Disorder

• Mood Stabilizers (Lithium and Valproate/depakote)

  • keeps the highs from getting too high and lows from getting too low

• Antipsychotics

  • Given prn during severe manic episodes for psychosis such as delusions and/or hallucinations

• Antidepressants

  • Can be given to treatment with depressive episodes but should be given with a

    mood stabilizer

Lithium Carbonate (Lithobid)

The oldest and most commonly used mood stabilizer

• MoA – unclear in how it affects neurotransmitters

• Monitor blood levels: 0.5 to 1.5 mEq/L is therapeutic level

• Nurse should consult with provider on patient’s EKG before starting first dose due to arrhythmias

• Pregnant women risk of teratogencity

Adverse Effects of Lithium

• Sedation

• Arrhythmias

• Excessive thirst, dry mouth, weight gain from water retention

• Pregnant women risk of teratogencity

• Lithium toxicity

Signs of Lithium Toxicity + Causes

• Severe tremor, ataxia, seizures, confusion, coma

• Nurses should look for signs of toxicity and look for last Lithium blood level before giving subsequent doses; and report findings to provider.

• Overdoses can be corrected with sodium bicarbonate or dialysis

• Common causes of low lithium blood levels

  • Non-compliance, eating too much salt (body retaining sodium not lithium, drinking too much water (diluting blood level)

  • Loop & thiazide diuretics can cause hyponatremia which can lead to lithium toxicity.

• Dietary consult and fluid and salt restriction/monitoring may be necessary

Valproate (Depakote)

Mood stabilizer

• MoA: unknown (one theory is that its enhances GABA and suppresses CNS)

• Therapeutic blood level is 50-100 mcg/mL

• Monitor for hepatotoxicity (monitor LFTs)

• Can cause thrombocytopenia (increased risk of bleeding)

• Can cause life threatening pancreatitis (abdominal pain, nausea, vomiting, anorexia)

• Can cause teratogenicity (fetal harm)

• Nurses should check blood level value before administering subsequent doses to prevent toxic levels

• Patients should not drive until response to drug is known

Adverse Effects of Valproate

• Sedation

• Drowsiness

• Headaches

• Tremor

• Muscle Weakness

Antipsychotics for Bipolar Disorder

Olanazapine (Zyprexa)

• Use of second generation antipsychotics is more common because they have fewer side effects than first generation side effects

• MoA: is unknown (believed to inhibit serotonin and dopamine)

• Common CNS adverse effect is somnolence

• Common endocrine adverse effect is weight gain and diabetes risk (baseline weight and lipid and blood sugar labs)

  • Disrupting serotonin changes appetite

Why is it recommended that a person with Bipolar Disorder not be placed on an antidepressant unless that person is on a mood stabilizer?

Typical antidepressants are CNS stimulants and could trigger a manic episode

What are some ways that we assess for risk for suicide and ask about suicidal ideations?

• We use direct and compassionate questioning techniques

  • normalizing questions

  • direct ideation questions

  • intent/plan questions

• We can use screening tools like the PHQ-9 (Item 9)

• Asses for a plan, the means, and intent

• Look at behavioral changes like withdrawal, giving away belongings

• Look at emotional changes like sudden calmness, hopelessness

• Look at nonverbal cues like poor eye contact, slowed speech

How does the Tarasoff Warning relate to working with a patient with a suicidal plan?

• Duty to Warn

  • Notify identifiable third party of threat

  • Not typically applied; suicide focuses on protecting the patient

• Duty to Protect

  • Take reasonable action to prevent harm

  • Initiate safety measures to prevent self-harm

• Triggering Condition

  • Credible threat to another person

  • Credible intent, plan, or means for self-harm

• Clinical Actions

  • Warn target, contact authorities, hospitalize

  • Notify care team, initiate precautions, emergency referral, emergency detention (Chapter 51), an involuntary admission to inpatient psychiatric unit

• Primary Goal

  • Protect potential victim

  • Ensure patient safety and prevent suicide

ECT

Electroconvulsive Therapy

• A medical treatment that uses small electrical currents to trigger a brief, controlled seizure in the brain while a patient is under general anesthesia

• Purpose is for treatment of severe depression, mania, or catatonia

• Main adverse effect is short-term memory loss - usually resolves quickly