3320 bipolar disorder

epidemiology

6th leading cause of disability in US, average age at onset is 25, associated with increased mortality and suicide, more often in higher SES

predisposing factors

genetics, excess NE or DA, neuroanatomical factors, medication side effects, psychosocial theories

bipolar characteristics

mood swings from profound depression to extreme euphoria/mania with intervening periods of normalcy, possible delusions or hallucinations, possible seasonal pattern of symptoms

mania

alteration in mood expressed by feelings of elation, inflated self-esteem, grandiosity, hyperactivity, agitation, racing thoughts, accelerated speech

manic thought process/speech pattern

circumstantial speech, tangential speech, loose associations, flight of ideas, coherent/incoherent, connected/disconnected, goal directed/not goal directed, logical/illogical

manic mood/behavior

euphoria, grandiosity, pressured speech, impulsivity, excessive libido, recklessness, social intrusiveness, diminished need for sleep

dysphoric mood/behavior

depression, anxiety, irritability, hostility, violence, suicide

mania cognitive symptoms

racing thoughts, distractability, disorganization, inattentiveness

manic psychotic symptoms

delusions, hallucinations

depressive symptoms

weight changes, sleep changes, fatigue, feelings of worthlessness, diminished cognitive abilities, loss of pleasure or interest, recurrent thoughts of death

acute phase

usually requires hospitalization to protect patient from harm, stabilization

continuation phase

4-9mo, goal to prevent relapse

maintenance treatment phase

focused on prevention and recurrence of episodes

bipolar 1

manic episode or history of 1 or more manic episodes and may have also experienced depressive episodes

diagnosis further specified by current/most recent behavioral episode

possible psychosis

bipolar 2

symptoms/history of depression or hypomania, never met criteria for full manic episode, has never had symptoms severe enough to cause impairment in social or occupational functioning or to necessitate hospitalization

developmental implications

ADHD is most common comorbid condition, Tx agents may exacerbate mania and should be administered only after bipolar symptoms have been controlled

mania- risk for self-directed or other-directed violence

remove all dangerous objects from environment, maintain calm attitude, lower level of stimuli, sufficient staff available to assist restraint if deemed necessary

mania- impaired social interaction

set limits on manipulative behaviors, don’t argue/bargain/try to reason with client, provide positive reinforcement

mania- imbalanced nutrition less than body requirements/insomnia

provide pt with high-protein high-calorie finger foods, maintain accurate record of I&O and calorie count, monitor sleep patterns

ECT for acute mania

used when patient does not tolerate/fails to respond to lithium/other drug Tx or when life threatened by dangerous behavior or exhaustion

bright light therapy

may benefit bipolar disorder, not associated with mood shifts toward manic episode

mania pharmacology

lithium carbonate, anticonvulsants, Ca channel blockers, antipsychotics

education on lithium

take regularly, don’t operate dangerous machinery, don’t skimp on dietary sodium and maintain appropriate diet, possible teratogenicity and risk of neonatal/fetal harm, carry ID noting taking lithium, side effects and symptoms of toxicity, notify HCP if vomiting/diarrhea, have serum lithium levels checked q1-2mo

lithium therapeutic range

 0.6-1.2mEq/L maintenance, 1.0-1.5mEq/L acute mania

lithium side effects

weight gain, tremor, polyuria, polydipsia, drowsiness, impaired coordination, nausea

lithium labs

periodic renal and thyroid function tests, baseline BUN and creatinine levels, Li levels

early signs of lithium toxicity

N&V, diarrhea, polydipsia, polyuria, lethargy, slurred speech, muscle weakness, fine hand tremors

advanced signs of lithium toxicity

coarse hand tremors, mental confusion, sedation, persistent GI upset, muscle hyperirritability, EEG changes, incoordination

severe lithium toxicity

ataxia, seizures, severe hypotension, blurred vision, clonic movement, large output of dilute urine, stupor, coma, death secondary to pulmonary complications, cardiac dysrhythmias, peripheral circulatory collapse

education on anticonvulsants/antiepileptics

refrain from discontinuing drug abruptly, report S/S to HCP (skin rash, sore throat, unusual bleeding, spontaneous bruising, fever, malaise, dark urine, jaundice), avoid alcohol and OTC meds without approval from HCP, monitor liver function and platelet count

anticonvulsants/antiepileptics

clonazepam/Klonopin, valproic acid/Depakene/Depakote, gabapentin/Neurontin, oxcarbazepine/Trileptal, pregabalin/Lyrica, lamotrigine/Lamictal (SJS), topiramate/Topamax (migraine prophylaxis, weight loss, renal calculi, metabolic acidosis), carbamazepine/Tegretol (lethal OD, agranulocytosis, aplastic anemia)

education on calcium channel blockers

take with meal if GI upset occurs, rise slowly from laying down/sitting to standing to prevent orthostatic hypotension

education on antipsychotics

used for schizophrenia and other psychotic disorders, select agents for bipolar disorder

antipsychotics

ziprasidone/Geodon, quetiapine/Seroquel, risperidone/Risperdal, olanzapine/Zyprexa, lurasidone/Latuda, aripiprazole/Abilify, asenapine/Saphris, Symbax (zyprexa+prozac)