Chapter 14: Bipolar Disorders

Chapter 14: Bipolar Disorders

Mood disorders with recurrent episodes of depression and mania.

Onset & Diagnosis

• Usually emerge in early adulthood.

• Early-onset bipolar disorder can occur in pediatric clients.

• Difficult to diagnose in children due to overlap with ADHD symptoms.

Course of Illness

• Alternating periods of:

  • Normal functioning

  • Illness (mania or depression)

• Some clients may struggle to maintain occupational and social functioning.

Symptoms During Mania

• Psychotic behavior (loss of touch with reality)

• Paranoid behavior

• Bizarre behavior

Care Phases for Bipolar Disorder

Acute Phase

• Hospitalization may be required.

• Goals: reduce mania, ensure client safety.

• Assess risk of harm to self or others.

• One-to-one supervision may be necessary for safety.

Continuation Phase

• Duration: 4 to 9 months.

• Goal: prevent relapse.

• Interventions: education, medication adherence, psychotherapy.

Maintenance Phase

• Duration: lifelong treatment.

• Goal: prevent future manic episodes.

A nurse is discussing relapse prevention with a client who has bipolar disorder. Which of the following information should the nurse include in the teaching?

Select all that apply.

a

Use caffeine in moderation to prevent relapse.

b

Difficulty sleeping can indicate a relapse.

c

Begin taking your medications as soon as a relapse begins.

d

Participating in psychotherapy can help prevent a relapse.

e

Anhedonia is a clinical manifestation of a depressive relapse.

b Difficulty sleeping can indicate a relapse.

d Participating in psychotherapy can help prevent a relapse.

e Anhedonia is a clinical manifestation of a depressive relapse.

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The client who has bipolar disorder should avoid the use of caffeine because it can precipitate a relapse.

The client who has bipolar disorder should take prescribed medications to prevent and minimize a relapse.

Behaviors Shown with Bipolar Disorders

Mania

• Abnormally elevated, expansive, or irritable mood.

• Usually requires hospitalization.

• Lasts at least 1 week.

Hypomania

• Less severe mania, lasts at least 4 days.

• Requires ≥3 manifestations of mania.

• Hospitalization not required, functioning less impaired.

• Can progress to mania.

Rapid Cycling

• ≥4 episodes of hypomania or acute mania within 1 year.

• Associated with increased recurrence and resistance to treatment.

Types of Bipolar Disorders

Bipolar I Disorder: At least one manic episode alternating with major depression.

Bipolar II Disorder: At least one or more hypomanic episodes alternating with major depression.

Cyclothymic Disorder: At least 2 years of repeated hypomanic symptoms alternating with minor depression, not meeting full diagnostic criteria.

Common Bipolar Comorbidities

Substance use disorder

Anxiety disorders

Borderline personality disorder

Oppositional defiant disorder

Social phobia / specific phobias

Seasonal affective disorder

ADHD

Migraines

Metabolic syndrome

Bipolar Risk Factors

Genetics: Immediate family member with bipolar disorder.

Physiological: Neurobiologic and neuroendocrine disorders.

Environmental: Stressful environments can trigger mania/depression and worsen symptoms in genetically susceptible children.

Relapse Triggers

• Substance use (alcohol, cocaine, caffeine).

• Sleep disturbances (can precede, accompany, or result from mania).

• Psychological stressors can trigger mania.

Bipolar Expected Findings (Manic)

Labile mood with euphoria

Agitation, irritability, restlessness

Dislike of interference, intolerance of criticism

Increased talking and activity

Flight of ideas: rapid, continuous speech, frequent topic changes

Grandiosity: inflated view of self and abilities

Impulsivity (spending/giving away money or possessions)

Demanding, manipulative behavior

Distractibility, decreased attention span

Poor judgment

Attention-seeking behavior (flashy dress, inappropriate actions)

Impairment in social/occupational functioning

Decreased need for sleep

Neglect of ADLs (nutrition, hydration, hygiene)

Possible delusions or hallucinations

Denial of illness

Bipolar Expected Finding (Depressive)

Flat, blunted, or labile affect

Tearfulness, crying

Low energy

Anhedonia (loss of pleasure in hobbies, activities, sex)

Physical discomfort/pain complaints

Difficulty concentrating, focusing, problem-solving

Self-destructive behavior, suicidal ideation

Decline in personal hygiene

Sleep changes: insomnia or hypersomnia

Psychomotor retardation or agitation

Bipolar Standardized Screening Tool

Altman Self Rating Mania Scale (ASRM): Assesses client’s placement on the continuum from depression to mania.

Useful for management and treatment planning.

Bipolar Nursing Care

Acute Manic Episode

Therapeutic Milieu (in acute care setting)

• Provide a safe environment.

• Assess for suicidal thoughts, intentions, escalating behavior.

• Decrease stimulation without isolation (control noise, TV, music, crowding).

• Use seclusion/restraints/1:1 observation if client poses a threat.

• Implement frequent rest periods.

• Provide outlets for physical activity (but avoid complex/detailed tasks).

• Protect from impulsive behaviors (e.g., giving away money, sexual indiscretions).

Maintenance of Self-Care Needs

• Monitor sleep, fluid, nutrition.

• Provide portable, nutritious food if unable to sit for meals.

• Supervise clothing choices.

• Give step-by-step reminders for hygiene and dress.

Communication Strategies

• Use calm, matter-of-fact, specific approach.

• Give concise explanations.

• Maintain consistency with expectations and limits.

• Avoid power struggles, don’t take comments personally.

• Listen to legitimate concerns.

• Reinforce non-manipulative behavior.

• Use therapeutic communication techniques.

Medications for Bipolar Disorders (MMA)

Mood Stabilizers (Lithium carbonate)

Mood-stabilizing Antiepileptic medications (Carbamazepine, Valproate, Lamotrigine)

Antipsychotics

• Lurasidone, olanzapine, quetiapine, aripiprazole, risperidone, asenapine, cariprazine, and ziprasidone are useful during acute mania with or without valproate or lithium.

• Ziprasidone, olanzapine, and aripiprazole can be used long-term as prophylaxis against mood episodes.

• Lurasidone is approved for bipolar depression.

Mood Stabilizers (Lithium carbonate) Action / Use

Produces neurochemical changes in the brain (serotonin receptor blockade)

Evidence: decreases neuronal atrophy and/or increases neuronal growth.

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Treatment of bipolar disorders.

Controls acute mania.

Prevents recurrence of mania/depression.

Decreases incidence of suicide.

Mood Stabilizers (Lithium carbonate) Complications / Contraindications

GI Distress

Fine Hand Tremors (worsened with stress/caffeine)

• May require propranolol

Polyuria / Mild Thirst

• May require potassium-sparing diuretic (spironolactone)

Weight Gain

Renal Toxicity

Goiter & Hypothyroidism (long-term treatment)

Brady-dysrhythmias, Hypotension, Electrolyte Imbalances

Lithium Toxicity

• Lithium level: < 1.5 mEq/L

• Manifestations: Nausea, diarrhea, thirst, polyuria, muscle weakness, fine tremors, slurred speech, lethargy.

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Pregnancy Risk: Category D (teratogenic, especially 1st trimester).

Avoid during breastfeeding if lithium therapy required.

Contraindicated in:

• Severe renal or cardiac disease

• Hypovolemia

• Schizophrenia

Use cautiously in:

• Older adults

• Clients with thyroid disease, seizure disorder, or diabetes

Lithium Toxicity

Common Adverse Effects

• Lithium level: < 1.5 mEq/L

• Manifestations: Nausea, diarrhea, thirst, polyuria, muscle weakness, fine tremors, slurred speech, lethargy.

• Nursing action: Reassure—symptoms at low levels usually improve over time.

Early Indications of Toxicity

• Lithium level: 1.5–2.0 mEq/L

• Manifestations: Mental confusion, sedation, poor coordination, coarse tremors, ongoing GI distress (nausea, vomiting, diarrhea).

• Nursing actions:

  • Withhold medication, notify provider.

  • Adjust dosage based on lithium/sodium levels.

  • Promote excretion as needed.

Advanced Indications of Toxicity

• Lithium level: 2.0–2.5 mEq/L

• Manifestations: Extreme polyuria, dilute urine, tinnitus, giddiness, jerking movements, blurred vision, ataxia, seizures, severe hypotension, stupor → coma, possible death (respiratory complications).

• Nursing actions:

  • Administer emetic or perform gastric lavage.

  • Prescribe urea, mannitol, or aminophylline to increase excretion.

Severe Toxicity

• Lithium level: > 2.5 mEq/L

• Manifestations: Rapid progression → coma → death.

• Nursing action: Hemodialysis may be warranted.

Mood Stabilizers (Lithium carbonate) Interactions / Admin

Diuretics

• Sodium is excreted with diuretics → low sodium = decreased lithium excretion → toxicity.

Nursing Actions

• Monitor for toxicity.

Client Education

• Watch for toxicity, notify provider.

• Maintain adequate sodium intake.

• Drink 1.5–3 L/day of fluids.

NSAIDs

• Concurrent use → ↑ renal reabsorption of lithium → toxicity.

• Nursing actions:

  • Avoid NSAIDs.

  • Use aspirin instead (does not cause toxicity).

Anticholinergics (antihistamines, TCAs)

• Cause urinary retention + polyuria → abdominal discomfort.

• Client education: Avoid meds with anticholinergic effects.

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Plasma lithium monitoring:

• Every 2–3 days at initiation until stable, then every 1–3 months.

• Obtain blood levels in the morning, 10–12 hrs after last dose.

• Initial manic episode: 1.0–1.5 mEq/L.

• Maintenance: 0.6–1.2 mEq/L.

Older adults: higher risk for toxicity → require more frequent monitoring.

Severe lithium toxicity: treat in acute care setting; hemodialysis may be needed.

Client teaching:

• Effects begin in 5–7 days; maximum benefits in 2–3 weeks.

• Take med as prescribed, in 2–3 doses daily (short half-life).

• Take with food to ↓ GI distress.

• Keep appointments for monitoring.

• Stress importance of adequate fluid and sodium intake.

• Provide nutritional counseling.

• Recognize signs of toxicity and know when to seek help.

Mood Stabilizers Meds

Prototype: Lithium carbonate

Mood-stabilizing Antiepileptic medications (Carbamazepine, Valproate, Lamotrigine) Action / Use

Slowing re-entry of sodium and calcium into neurons → prolongs nerve recovery.

• Potentiating GABA (inhibitory neurotransmitter).

• Inhibiting glutamate → suppresses CNS excitation.

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Treats and prevents relapse of manic and depressive episodes.

Especially effective in mixed mania and rapid-cycling bipolar disorder.

Mood-stabilizing Antiepileptic medications (Carbamazepine) Complications / Contraindications

CNS Effects

• Nystagmus

• Double vision

• Vertigo

• Staggering gait

• Headache

Nursing Actions

• Start with low doses, gradually increase.

• Administer at bedtime.

• Client education: effects usually subside within weeks.

Blood Dyscrasias

• Leukopenia, anemia, thrombocytopenia.

Nursing Actions

• Monitor CBC, platelets at baseline and ongoing.

• Watch for bruising, gum bleeding (signs of thrombocytopenia).

• Monitor for infection (fever, lethargy).

• Client education: notify provider if blood dyscrasias suspected.

Teratogenesis

• Avoid in pregnancy.

Hypo-osmolarity

• Promotes SIADH → water retention, ↓ excretion → fluid overload (risk with heart failure).

Nursing Actions

• Monitor sodium, edema, urine output, hypertension.

Skin Disorders

• Includes dermatitis, rash, Stevens-Johnson syndrome.

Nursing Actions

• Treat mild rashes with anti-inflammatory or antihistamines.

• Client education:

  • Stop med and notify provider if SJS occurs.

  • Wear sunscreen to reduce risk of skin disorders.

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Oral contraceptives, warfarin → ↓ effectiveness due to ↑ metabolism.

• Nursing: Monitor therapeutic effects, adjust dosages.

• Client: Use alternate birth control.

Grapefruit juice → inhibits metabolism → ↑ levels.

• Client: Avoid grapefruit juice.

Other anticonvulsants → ↓ effectiveness.

• Nursing: Monitor drug levels, adjust as needed.

Mood-stabilizing Antiepileptic medications (Lamotrigine) Complications / Contraindications

CNS Effects: Double/blurred vision, dizziness, headache, nausea, vomiting.

• Client education: Avoid activities requiring concentration or visual acuity.

Serious Skin Rashes (Stevens-Johnson syndrome).

• Client education: Stop med & notify provider if rash occurs.

• Start with low dose and titrate slowly to minimize risk.

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Carbamazepine, phenytoin, phenobarbital → ↓ effect.

• Nursing: Monitor and adjust.

Valproate → inhibits metabolism → ↑ half-life.

• Nursing: Monitor for adverse effects.

Oral contraceptives → ↓ effectiveness of both drugs.

• Client: Use alternate birth control.

Mood-stabilizing Antiepileptic medications (Valproate) Complications / Interactions

GI Effects

• Nausea, vomiting, indigestion.

• Client education: Usually self-limiting; take with food or use enteric-coated form.

Hepatotoxicity

• Signs: anorexia, nausea, vomiting, fatigue, abdominal pain, jaundice.

• Nursing actions:

  • Monitor baseline liver function, then every 2 months during first 6 months.

  • Avoid in children <2 years.

  • Use lowest effective dose.

• Client education: Report hepatotoxicity symptoms immediately.

Pancreatitis

• Signs: nausea, vomiting, abdominal pain.

• Nursing actions:

  • Monitor amylase levels.

  • Discontinue if pancreatitis develops.

• Client education: Report symptoms immediately.

Thrombocytopenia

• Nursing action: Monitor platelets.

• Client education: Watch for bruising, report if occurs.

Teratogenesis

• Client education:

  • Avoid during pregnancy.

  • If pregnant, discuss alternative treatments.

Weight Gain

• Client education: Maintain healthy diet and exercise.

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Other anticonvulsants → alter levels.

• Nursing: Monitor and adjust.

Mood-stabilizing Antiepileptic medications (Carbamazepine, Valproate, Lamotrigine) Contraindications

Pregnancy Risk Category D → teratogenic, risk of birth defects.

Carbamazepine contraindicated with bone marrow suppression or bleeding disorders.

Monitor valproate and carbamazepine plasma levels:

• Carbamazepine therapeutic range: 4–12 mcg/mL

• Valproic acid therapeutic range: 50–120 mcg/mL

Lamotrigine must be titrated slowly to prevent adverse effects.

Mood-stabilizing Antiepileptic medications

Prototype Medications

• Carbamazepine

• Valproate

• Lamotrigine

Nursing Evaluation of Bipolar Medication Effectiveness

Relief of manic symptoms (flight of ideas, excessive talking, agitation).

Relief of depressive symptoms (fatigue, poor appetite, psychomotor retardation).

Verbalization of mood improvement.

Improved ADLs and eating habits.

Appropriate peer interactions.

Antipsychotics

Lurasidone, olanzapine, quetiapine, aripiprazole, risperidone, asenapine, cariprazine, ziprasidone

• Useful in acute mania (with or without valproate/lithium).

Ziprasidone, olanzapine, aripiprazole → can be used long-term prophylaxis against mood episodes.

Lurasidone → approved for bipolar depression.

BipolarTherapeutic Procedures

Electroconvulsive Therapy (ECT)

• Used for extreme manic behavior when lithium/other meds fail.

• Beneficial for suicidal clients or those with rapid cycling.

Mania Complications

Physical exhaustion → possible death

• Client in manic state may not eat, drink, or sleep. → Medical emergency

Nursing Actions

• Prevent self-harm.

• Decrease physical activity.

• Ensure adequate nutrition & fluids.

• Promote adequate sleep.

• Assist with self-care needs.

• Manage medications appropriately.

Client Education

• Case management → ensures follow-up for client & family.

• Encourage psychotherapy (individual, group, family → CBT).

  • Improves problem-solving & interpersonal skills.

Health Teaching

• Bipolar disorder is chronic → requires long-term med + psychological support.

• Benefits of therapy/support groups → relapse prevention.

• Teach warning signs of relapse and crisis management strategies.

• Recognize precipitating factors: sleep disturbance, alcohol, caffeine.

• Stress importance of regular sleep, meals, activity routine.

• Medication adherence is essential.

A nurse is discussing early indications of toxicity with a client who has a new prescription for lithium carbonate for bipolar disorder. The nurse should include which of the following manifestations in the teaching?

Select all that apply.

a

Constipation​​​​​​​ 

b

Polyuria

c

Rash

d

Muscle weakness

e

Tinnitus

b Polyuria

d Muscle weakness

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Tinnitus is an indication of severe, rather than early, toxicity.

A nurse is admitting a client who has a new diagnosis of bipolar disorder and is scheduled to begin lithium therapy. When collecting a medical history from the client’s caregiver, which of the following statements is the priority to report to the provider?

a

“Current medical conditions include diabetes that is controlled by diet.”

b

“Recent medications include a course of prednisone for acute bronchitis.”

c

“Current vaccinations include a flu vaccine last month.”

d

“Current medications include furosemide for congestive heart failure.”

d “Current medications include furosemide for congestive heart failure.”

A nurse is discussing routine follow-up needs with a client who has a new prescription for valproate. The nurse should inform the client of the need for routine monitoring of which of the following?

a

AST/ALT and LDH

b

Creatinine and BUN

c

WBC and granulocyte counts

d

Blood sodium and potassium

a AST/ALT and LDH