Bipolar Disorder

Exam 1 - sem 3

Bipolar Epidemiology

• Affects approximately 4.4% of U.S. adults with 89% of those cases being severe

• Incidence equal between men and women

• Average age of onset – age 25, and following 1^st manic episode the disorder tends to be recurrent.

• More frequent in higher socioeconomic class

• 6^th leading cause of disability in the middle-age group in the U. S.

Bipolar spectrum

Bipolar disorder

• Characterized by mood swings from profound depression to extreme euphoria

• Intervening periods of normalcy

• Delusions or hallucinations may be present

Mania

An alteration in mood that is expressed by feelings of elation, inflated self-esteem, grandiosity, hyperactivity, agitation, and accelerated thinking and speaking

Manic episode

• Mood is elevated, expansive, or irritable

• Marked impairment in occupational or social functions

• Motor activity is excessive and frenzied

• Psychotic feature may be present

• Client may need to be hospitalized for safety of themselves and others

• Patients may like this phase as they have increase energy and feels like they “take in the world”

• Patient may refuse medications that will “bring them down”

• Moving a lot → not eating → burning a lot of calories → not sleeping → losing weight

Hypomania

A mild form of mania

Symptoms are excessive hyperactivity, but not sever enough to cause marked impairment in social or occupational functioning or to require hospitalization

May come across as more irritable

May become mania if untreated

Types of Bipolar Disorder

Bipolar I

Bipolar II

Cyclothymic Disorder

Substance/Medication-Induced Bipolar Disorder

Bipolar Disorder due to another medical condition

Bipolar I and II

Diagnostic picture the same as for MDD expect the client must have a history of one or more manic/hypomanic episodes

Bipolar I Disorder

Client who is currently experiencing a manic episode or has a history of more than one manic episodes

May have also experienced episodes of depression

Psychotic or catatonic feature may also be noted

Bipolar II disorder

Recurrent bouts of major depression with episodic occurrence of hypomania

Cyclothymic Disorder

Chronic mood disturbance of at least 2 years duration, involving numerous periods of elevated mood that do not meet the criteria for a hypomanic episode and numerous periods of depressed mood of insufficient severity to meet criteria for Major Depressive Disorder (chronic low-level depression)

Substance and Medication-Induced Bipolar Disorder

• The disturbance of mood is a direct result of physiological effects of a substance (ingestion of or withdrawal from a drug of abuse or a medication)

• The mood disturbance may involve elevated, expansive, or irritable mood with inflated self-esteem, decreased need for sleep, and distractibility

• Mood disturbances are associated with intoxication from substances such as alcohol, amphetamines, cocaine, hallucinogens, inhalants, opioids, phencyclidine, sedatives, hypnotics, and anxiolytics

• A number of prescribed medications have been known to evoke mood symptoms

Predisposing factors of bipolar

Strong genetic vulnerability

• Research suggests that bipolar disorder strongly reflects an underlying genetic vulnerability 

• Twin studies have indicated a concordance rate for bipolar disorder among monozygotic (identical) twins at 60 to 80 percent compared to 10 to 20 percent in dizogotic (fraternal) twins

• Show that if one parent has a mood disorder, the risk that a child will have a mood disorder is between 10 and 25 percent

• If both parents have the disorder, the risk is two to three times as great

Nursing Diagnoses for bipolar

Risk for Injury

Risk for Violence: To self or others

Imbalanced Nutrition: Less Than Body Requirements

Disturbed Sleep Pattern

Impaired Social Interaction

Nursing Interventions for bipolar

• SAFETY FIRST! Remove hazardous objects

• Reduce environmental stimuli

• Limit group activities until appropriate

• Observe client’s behavior and assess for behaviors that are a safety risk; manic patients can be impulsive

• Maintain calm attitude

• Be prepared to administer PRN medications

• Offer high protein, high calorie finger foods for pacing client

• Record I & O’s, lab values, weight

• Set limits on manipulative behaviors – communicate these limits to all staff

• Do not argue, bargain or try to reason with the client. Be direct

• Follow through with consequences

• Provide positive reinforcement for good behaviors

• Protect the client’s privacy as much as you can (they like to walk around naked)

The nurse is prioritizing nursing diagnosis in the plan of care for a patient experiencing a manic episode.  Number the diagnoses in order of the appropriate priority:

1. Disturbed sleep pattern AEB sleeping only 4-5 hours a night

2. Risk for injury r/t manic hyperactivity

3. Impaired social interaction AEB manipulation of others

4. Imbalanced nutrition AEB wt loss and poor skin turger

PUT IN ORDER

2, 4, 1, 3

Education for bipolar

Medication teaching

Importance of compliance

Educate the FAMILY about illness to help them understand

Give community resources

*They may be frustrated when they are doing everything right, but you aren’t getting better

What about kids with bipolar?

The biggest comorbidities are ADHD and conduct disorders, making it hard to diagnose

Because stimulants can exacerbate mania, it is suggested that medication for ADHD be initiated ONLY after bipolar symptoms have been controlled with a mood stabilizing agent

Bipolar disorder treatments

• Individual Psychotherapy

• Group Therapy

• Family Therapy

• Cognitive Therapy

• ECT

• Pharmacology

Mood Stabilizers

lithium (Lithobid)

Anti-epileptics/Anti-convulsants

carbamazepine (Tegretol)

lamotrigine (Lamictal)

valproate (Depakote)

Atypical Antipsychotics

olanzapine (Zyprexa)

quetiapine (Seroquel)

risperidone (Risperdal)

aripiprazole (Abilify)

haloperidol (Haldol)

Mood stabilizing drugs are used for what to treat bipolar?

Stabilizing the client’s mood

Preventing or minimizing the high and lows of character

Lithium

7-14 days to take effect

Need to get pregnancy test prior to start (manic episodes tend to start at 25 which is also prime child bearing age)

Check kidney/thyroid function

My be used with atypical antipsychotics (risperidone, olanzapine, aripiprazole)

• Decreases agitation and restlessness until mood stabilizer kicks in

Lithium side effects and nursing interventions

GI DISTRESS – Give med with food or milk, advise client GI symptoms usually transient

FINE HAND TREMORS – Administer beta blocker such as Inderal.  Educate client to report increase as could be signs of lithium toxicity

• Mild tremors are normal, horse tremors are when we start to get concerned

POLYURIA, MILD THIRST –encourage adequate fluid intake

WEIGHT GAIN – Educate about the importance of living a healthy lifestyle

RENAL TOXICITY – Monitor I&O, assess and monitor BUN, creatinine, kidney function

GOITER & HYPOTHYROIDISM – Baseline T3, T4 and TSH levels and then annually.  Educate about signs of hypothyroidism (cold, dry skin, decreased HR, weight gain.  Administer levothyroxine (Synthroid)

CARDIAC — arrhythmias, hypotension, electrolyte imbalances-maintain adequate fluid and sodium intake

Therapeutic Lithium levels

0.6-1.2 mEq/L

Early indication of lithium toxicity

Less than 1.5 mEq/L

D, N, V, and polyuria

Muscle weakness, FINE hand tremors

Slurred speech

Hold the med and contact provider

Advanced indication of lithium toxicity

1.5-2.0 mEq/L

Mental confusion, poor coordination

COURSE tremors

Ongoing GI distress

Hold the med, contact provider

Excretion mat need to be promoted

Severe indication of lithium toxicity

2.0-2.5 mEq/L

Extreme polyuria of dilute urine

Tinnitus, seizure, blurred vision

Severe hypotension, respiratory complications

Administer an emetic or gastric lavage

Urea, mannitol, or aminophylline

• to increase rate of excretion

Extreme indication of lithium toxicity

Greater than 2.5 mEq/L

Coma or death

May attempt hemodialysis

Administration of Lithium

Monitor plasma lithium levels Q 2-3 days until stable, then every 1 – 3 months

Lithium blood levels should be obtained in the morning, usually 12 from hours last dose

Administered 2 – 3 times a day due to short half life

Lithium contraindications

Pregnancy

Breastfeeding

Use cautiously in renal dysfunction, heart disease, sodium depletion, and dehydration

Lithium patient education

Take as ordered: double up on dose if dose missed - take within the day

BLOOD levels as ordered 

Increased risk of toxicity in elderly 

Do not use if pregnant 

7-14 days to take effect 

Take with food to decrease GI distress 

Maintain fluid and sodium intake

NSAIDS: Increase renal reabsorption of lithium = toxicity: ASA is better choice 

Diuretics: May cause toxicity (sodium decrease=lithium increase=toxic)

Signs and symptoms of toxicity 

Adverse effects of carbamazepine (Tegretol)

Blood dyscrasias (leukopenia, anemia, thrombocytopenia)

Teratogenesis (congenital malformations in fetus)

Hypo-osmolarity/hyponatremia (watch in CHF)

Stevens-Johnson syndrome (rash)

• all over body rash that is lethal if not treated

Also many drug/drug interactions with Tegretol

Adverse effects lamotrigine (Lamictal)

Stevens-Johnson syndrome (Begins with flu-like symptoms followed by a painful red or purplish rash that spreads and blisters. Top layer dies and sheds)

Double/Blurred vision

Dizziness

Headache

Nausea/Vomiting

Start low and go slow!

Adverse effects of valproic acid (Depakote)

GI → Give with food

Hepatotoxicity(liver function tests Q 2 months)

Pancreatitis

Thrombocytopenia (monitor platelet counts)

Teratogenesis/PCOS - consider alternative for females of child bearing years (toxic to fetus)

Decreases effectiveness of oral contraceptives: this is for all antiepileptics

CONTRAINDICATED in clients who have bone marrow suppression, bleeding disorders, liver disorders

Weight gain

Patient education of valproic acid (Depakote)

Baseline and routine monitoring of AST/ALT and LDH

Monitor for signs and symptoms of Steven Johnson Syndrome 

Monitor Depakote level and ammonia levels regularly during treatment

Brain stimulation therapies

Electroconvulsive therapy (ECT)

Transcranial magnetic stimulation (TMS)

Vagus nerve stimulation (VNS)

What is electroconvulsive therapy?

ECT uses electrical current to induce brief seizure activity while the client is under anesthesia

Electroconvulsive Therapy (ECT)

Mechanism of action – biochemical – electrical stimulation results in significant increases in the circulatory levels of several neurotransmitters, such as serotonin, norepinephrine, dopamine, and possibly glutamate and gamma aminobutyric (GABA)

ECT indications

Major depressive disorder

• Not responsive to medication

• Risks of other treatments outweigh risks of ECT

• Client is suicidal/homicidal

• Client is depressed with psychotic features

Schizophrenia

• Catatonic clients

• Schizoaffective disorder

Acute manic episodes

• Bipolar disorder with rapid cycling

• Clients unresponsive to treatment with lithium and antipsychotic medications

ECT contraindications

There are no absolute contraindications, however must assess the client for conditions that could place the client at higher risk for adverse effects:

• Cardiovascular disorders: recent MI’s, HTN, heart failure, arrhythmias. ECT increases stress on the heart during treatment

• Cerebrovascular disorders: hx of stroke, brain tumor, subdural hematoma.  ECT increases intracranial pressure during treatment

How ECT works

Typical course of treatment: 2-3 times a week for 6-12 weeks

Can be performed either inpatient or outpatient

Need to obtain informed consent

Pre—ECT workup: chest x-ray, labwork, EKG, spinal x-ray, EEG

Discontinue any benzodiazepine use as they can interfere with seizure process

ECT is not a permanent cure and may need follow up maintenance treatments

Usually on a muscle relaxer as well

ECT medication management for treatment

30 minutes prior to procedure: IM injection of atropine sulfate or glycopyrrolate administered to decrease secretions

At time of procedure: anesthesiologist administers a short-acting anesthetic (propofol) via IV bolus

A muscle relaxant  (succinylcholine) is also administered to paralyze the client’s muscles during seizure activity to decrease risk for injury.  This med also paralyzes the respiratory muscles so the client requires assistance with breathing and oxygenation

There might be memory loss from the day ECT happened

IV has to be hep-locked

ECT nursing mangment

Monitor VS and mental status prior and after ECT procedure

Assess the client’s and family’s understanding and knowledge of the procedure and provide teaching as necessary

Client will have a hep-lock/IV that will be used for treatments..need to assess and document

Clients are expected to become alert 15 minutes following ECT

ECT complications

Memory loss and confusion

• Occurs immediately following the procedure and can persist for several hours.

• Can have retrograde amnesia: loss of memory of events leading up to the procedure

• Can persist for several weeks

ECT nursing actions

Provide frequent orientation

Provide a safe environment

Assist client with hygiene as needed

Monitor for reactions to anesthesia

Monitor VS and cardiac rhythms

Transcranial Magnetic Stimulation (TMS)

• Currently approved for the treatment of Major Depressive Disorder

• An electrical magnetic coil is placed on the scalp.  Pulsed high-intensity current (MRI strength) passes through the coil, creating powerful magnetic fields that change the way brain cells function

• Treatments last for 20-40 min a session and must be 5 days a week for appx 5-6 weeks

• Limited insurance coverage, but improving.  It is very expensive and results are inconclusive for treatment of depression

• Unlike ECT, no seizure activity occurs

• Minimal side effects v. ECT

• Less invasive than ECT

Happens outpatient

TMS contraindications

Clients with cochlear implants, brain stimulators, medication pumps, pacemakers because the metal in the devices can interfere with treatment