Bipolar Disorder

Define Bipolar Disorder

A depressive episode with previous or current manic episod

Mood, Affect, Mania of Bipolar Disorder

• Mood: A pervasive and sustained emotion that influences perception.

  • Examples: Depression, joy, elation, anger, anxiety.

• Affect: The emotional reaction associated with an experience.

• Mania:

  • Elevated or irritable mood.

What is bipolar mania characterized by?

• Feelings of elation

• Inflated self-esteem

• Grandiosity

• Hyperactivity & agitation

• Accelerated thinking & speaking

Epidemiology - Age of Onset

• Age of Onset: Late teens to early 20s.

Epidemiology - Gender Differences

• Gender Differences:

  • Men & Women affected equally.

  • Women: First episode typically manic, but overall more depressive episodes.

  • Men: First episode typically depressive, but overall more manic episodes.

Epidemiology - Higher Risk Groups

• More common in higher socioeconomic classes.

• More frequently seen in socially active & creative individuals.

Causes of Bipolar

• No single cause identified.

• Neurotransmitter Dysregulation:

  • Imbalance in norepinephrine & serotonin levels.

• Genetic Linkage:

  • 25% increased risk if a first-degree relative has bipolar disorder.

Manic Episodes

• Episodes can last several weeks.

• Delusions or hallucinations may or may not be present.

• Onset may follow a seasonal pattern.

• Hospitalization often required for severe episodes.

• Symptoms are not due to other causes.

Manic Symptoms

• Persistent, elevated, expansive, or irritable mood lasting > 1 week.

• Decreased need for sleep (may not sleep at all but still feel energetic).

• Pressured speech (talking too fast, difficult to understand, can’t stop).

• Distractibility (easily diverted, inability to focus).

• Increased energy & hyperactivity (excessive goal-directed activity).

• Impaired judgment (risky behaviors, reckless spending).

• High rate of infidelity & divorces (due to impulsivity).

Clinical Behavior of Bipolar Disorder

• Mood instability (labile, easily agitated).

• Racing thoughts (rapid, disorganized thinking).

• Impaired judgment & concentration.

• Little to no sleep, but doesn’t feel the need.

• Excessive engagement in pleasurable activities (e.g., sexual encounters, intrusive behaviors).

• Grandiosity (inflated self-importance, unrealistic confidence).

• Possible delusions or hallucinations.

Consequences of untreated bipolar disorder

• Consequences of untreated bipolar disorder:

  • Alienation from family/friends

  • Divorce

  • Job loss

  • High suicide risk

Chronic cyclic disorder

• Chronic, cyclic disorder → time between episodes shortens over time.

• 90% of patients will experience future episodes.

• Repeated hospitalizations may be required.

Mood Stabilizers and Lithium Carbonate - Sleep

Behavioral and Sleep Considerations:

• Accepts responsibility for own behaviors

• Does not manipulate others for personal gratification

• Interacts appropriately with others

• Able to fall asleep within 30 minutes of retiring

• Able to sleep 6-8 hours per night

Mania - Depressive Phase

• Antidepressants (use with caution as they may trigger mania)

• Mood-stabilizing agents (e.g., Lithium, anticonvulsants, antipsychotics)

• Indications: Prevention and treatment of manic episodes associated with bipolar disorder

Names of Mood Stabilizers

• Lithium carbonate

• Clonazepam

• Carbamazepine

• Valproic acid

• Lamotrigine

• Gabapentin

• Topiramate

• Oxcarbazepine

• Verapamil

• Antipsychotics

Lithium Carbonate - Indications, Therapeutic Index, Blood Monitoring, Combined Use

• Indications: Treatment and prevention of manic episodes in bipolar disorder

• Narrow Therapeutic Index:

  • Therapeutic range: 0.5 – 1.2 mEq/L

  • Initial therapeutic target for acute mania: 1.0 to 1.5 mEq/L

  • Maintenance level: 0.6 to 1.2 mEq/L

• Blood Monitoring: Regular blood level checks required

• Combined Use: Often combined with antipsychotics or antianxiety medications during the initial phase of treatment (response > 1 week)

Side Effects of Lithium

• Fine hand tremor

• Gastrointestinal disturbances

• Mild polyuria (increased urination) and polydipsia (increased thirst)

• Lethargy

Lithium Toxicity

• Initial Symptoms of Toxicity:

  • Blurred vision

  • Ataxia (lack of muscle coordination)

  • Tinnitus (ringing in ears)

  • Persistent nausea and vomiting

  • Severe diarrhea

• Management of Toxicity:

  • Therapeutic Range:

    • Acute mania: 1.0 to 1.5 mEq/L

    • Maintenance: 0.6 to 1.2 mEq/L

  • Signs of toxicity when levels exceed the therapeutic range.

Lithium and Sodium

• Increased dietary sodium → Decreased serum lithium levels

• Decreased sodium (from diet or loss due to vomiting/diarrhea) → Increased serum lithium levels

  • Patient Teaching:

    • Maintain consistent salt intake based on their diet

    • Monitor sodium intake carefully

Nurse Intervention for Lithium

• Medication Adherence:

  • Take lithium regularly as prescribed

  • Do not skip or reduce dietary sodium intake without medical advice

  • Drink 6-8 glasses of water per day to prevent dehydration

  • Notify Physician if vomiting or diarrhea occur as it can affect lithium levels

  • Have serum lithium levels checked every 1-2 months, or as directed by the physician

• Notify Physician if Any of the Following Symptoms Occur:

  • Persistent nausea and vomiting

  • Severe diarrhea

  • Ataxia

  • Blurred vision

  • Tinnitus

  • Excessive urination

  • Increasing tremors

  • Mental confusion

Anticonvulsants

General Instructions:

• Do not discontinue the drug abruptly without medical advice to avoid withdrawal seizures or other complications.

• Notify the physician immediately if any of the following symptoms occur:

  • Skin rash

  • Unusual bleeding

  • Spontaneous bruising

  • Sore throat

  • Fever

  • Malaise

  • Dark urine

  • Yellow skin or eyes (potential signs of liver problems)

• Avoid alcohol and over-the-counter medications unless approved by the physician to prevent interactions.

Anticonvulsant - Side Effects

• General Side Effects:

  • Nausea and vomiting

  • Drowsiness and dizziness

  • Prolonged bleeding time (particularly with valproic acid)

  • Risk of severe rash (especially with lamotrigine)

  • Decreased efficacy of oral contraceptives (with topiramate)

Anticonvulsant - Medication Names

• Clonazepam (Klonopin)

• Topiramate (Topamax)

• Valproic Acid (Depakote)

• Lamotrigine (Lamictal)

• Carbamazepine (Tegretol)

• Oxcarbazepine (Trileptal)

Anticonvulsant - Patient Education

• Medication Adherence: Always take anticonvulsants as prescribed. Do not adjust the dose or stop the medication without consulting the physician.

• Monitor for Symptoms: Be vigilant for signs of serious reactions like skin rash, unusual bleeding, or liver issues (yellowing of skin/eyes, dark urine).

• Avoid Alcohol and OTC Medications: Discuss all medications, including OTC drugs, with your doctor to prevent interactions.

• Contraceptive Considerations: For women on anticonvulsants, topiramate can decrease the efficacy of oral contraceptives, so an alternative form of contraception may be necessary.

Verapamil (Calcium Channel Blockers) - Side Effects

Monitor for Side Effects of Verapamil:

• Drowsiness and dizziness

• Hypotension and bradycardia (slow heart rate)

• Nausea

• Constipation

Verapamil (Calcium Channel Blockers) - Patient Education

Patient Education:

• Do not discontinue the drug abruptly: Stopping verapamil suddenly can cause a rebound increase in heart rate and blood pressure. Always consult a physician before adjusting the medication regimen.

• Rise slowly: To prevent sudden drops in blood pressure, patients should rise slowly from sitting or lying positions.

• Report the following symptoms to the physician immediately:

  • Irregular heartbeat or chest pain

  • Shortness of breath or pronounced dizziness

  • Swelling of hands and feet

  • Profound mood swings

  • Severe and persistent headache

Verapamil - Nursing Implications

• Monitor vital signs regularly, especially heart rate and blood pressure.

• Check for signs of fluid retention (swelling of the extremities) and assess the patient's electrolyte levels if necessary.

• Ensure adequate hydration and provide education on dietary fiber to manage constipation.

Antipsychotics - Medication Names

Common Antipsychotic Medications:

• Risperidone (Risperdal)

• Ziprasidone (Geodon)

• Quetiapine (Seroquel)

• Aripiprazole (Abilify)

Antipsychotic - Patient Education

• Do not discontinue the drug abruptly: Stopping antipsychotics suddenly can lead to withdrawal symptoms or a relapse of psychiatric symptoms. Always consult a healthcare provider before making any changes.

• Use sunblock lotion when outdoors: Antipsychotics can increase sensitivity to sunlight, leading to sunburn.

• Rise slowly from sitting or lying position: These medications may cause orthostatic hypotension, leading to dizziness or fainting.

• Avoid alcohol and over-the-counter medications: Alcohol and certain OTC medications may interact with antipsychotics, increasing the risk of adverse effects.

• Continue taking the medication, even if feeling well and as though it is not needed: Symptoms may return if the medication is discontinued prematurely.

Antipsychotic - Symptoms

• Sore throat, fever, malaise (could indicate agranulocytosis, a severe side effect)

• Persistent nausea and vomiting

• Severe headache and rapid heart rate

• Difficulty urinating or excessive urination

• Muscle twitching, tremors (could indicate extrapyramidal symptoms or tardive dyskinesia)

• Darkly colored urine or pale stools (signs of liver dysfunction)

• Yellow skin or eyes (jaundice, possible liver issues)

• Excessive thirst or hunger (possible sign of metabolic disturbances, including diabetes)

• Muscular incoordination or weakness (may indicate neuroleptic malignant syndrome, a rare but serious condition)

Antipsychotic - Nursing Implication

• Monitor vital signs regularly, especially heart rate and blood pressure.

• Monitor for signs of infection (sore throat, fever, malaise), and check white blood cell count if necessary.

• Monitor for extrapyramidal side effects (tremors, rigidity, muscle twitching).

• Assess for signs of metabolic syndrome, including weight gain, excessive thirst, and hunger.

• Encourage regular check-ups and laboratory tests, including liver function and glucose levels, for long-term use.