Bipolar Disorder

Bipolar disorder 1

The presence of 1 MANIC episode

Typically even depression is more profound and severe

Suicidality risk

• Impulsivity associated with the diagnosis

• Risk of suicide is 15x greater than that of the general poopulation

Rapid cycling

• Four or more episodes in 12 months

• Associated with poorer outcomes

Bipolar 2

The presence of

• Hypomanic episode

• One major depressive episode

• A manic episode excludes this diagnosis

Diagnosis

• Very difficult to recognize and can incorrectly be treated with SSRIs which may worsen disease trajectory

• Yers of evaluation before eventual identification

Mood stabilizers

Anticonvulsants

• Valproate (Depakote)

  • Depakote (ER, sprinkles etc)

  • Divalproex Sodium

  • Valproic acid

• Lamotrigine (Lamictal)

• Carbamazepine (Tegretol)

• Oxcarbazepine (Trileptal)

Lithium therapeutic range

0.6-0.12 mEq/L

Lithium toxicity signs

Early signs can be tremors (can be normal side effect), Ataxia, vomiting (very fine tremor may occur even at therapeutic levels)

Profound signs of toxicity: mental status change, confusion, coma

Valproate side effects

nausea, vomiting, abdominal pain, dizziness, tremor , weight

Valproate monitoring

Liver function: Regular liver function tests

Platelet count: monitor for thrombocytopenia

Lamotrigine side effects

Common: dizziness, headache, blurred vision, coordination problems, GI disturbances

Serious: Severe skin rashes (Stevens-Johnsons syndrome), toxic epidermal necrolysis, multi-organ hypersensitivity reaction, Asperic meningitis

Lamotrigine monitoring

Skin reactions: watch for rashes, especially intially

Carbamazepine and Oxcarbazepine side effects

dizziness, drowsiness, nausea, vomiting, ataxia, visual disturbances

Carbamazepine and Oxcarbazepine monitoring

Complete blood count: Watch for signs of blood dycrasias (agrunlocytosis, aplastic anemia)

Treatment that can induce mania

Antidepressants: Can trigger a mood switch into mania, especially when prescribed as monotherapy or without an accompanying mood-stabilizing agent.

Stimulants: Central nervous system stimulants can unmask or induce manic symptoms.

Hormone Therapies: Corticosteroids and other hormonal preparations can cause mood elevations or instability.

Prescription & Illicit Substances: Other pharmaceuticals, alcohol, and synthetic or illicit substances can precipitate mania.

Caring for someone with bipolar disorder and priority

Risk for suicide (Main priority)

risk for impaired physiological functioning

• Self-care deficit

• Decreased fluid intake

• Decreased nutritional status

• Impaired tissue integrity

• Disturbed sleep pattern

Non adherence

Non-adherence refers to a patient not taking medications as prescribed, which poses a significant challenge in managing bipolar disorder.

• Risk Factors & Triggers: Non-adherence can stem from side effects, complexity of regimens, medication resistance, or disruptions to daily routines (e.g., changing living environments).

• Consequences: Sudden discontinuation of mood stabilizers or anti-epileptics can lead to relapse, increased seizure risk (if applicable), and severe manic episodes requiring hospitalization.

• Nursing & Clinical Interventions:

  • Adherence Aids: Utilizing medication planners or pre-packed medication systems.

  • Long-Acting Injections (LAIs): Administering long-acting injectable antipsychotics to ensure consistent therapeutic coverage.

  • Structured Schedules & Rhythms: Establishing strict daily routines (e.g., Interpersonal Social Rhythm Therapy concepts) and offering supportive community/outpatient care to maintain stability.

Impaired insight

Impaired insight is the inability or limited capacity of an individual to recognize that they have a mental health condition or that their symptoms require treatment.

• Egosyntonic Nature of Mania: During manic phases, elevated mood, euphoria, or grandiosity often feel positive or natural to the patient (egosyntonic), making them resistant to treatment or hospitalization.

• Clinical Implications:

  • Leads to treatment refusal, medication resistance, and chronic involuntary hospitalizations.

  • During severe manic states with impaired insight, loss of sensory perception can occur—patients may fail to feel hunger, thirst, cold, or physical pain, leading to significant physiological injury, dehydration, or skin breakdown.

• Nursing Role: When impaired insight prevents self-care, nurses must intervene directly to maintain physiological functioning (ensuring hydration, nourishment, sleep, and physical safety) and establish environmental supports for calmness until stability and insight are restored.