bipolar disorder and brain stimulation therapies

electroconvulsive therapy

a biomedical therapy where a brief electric current is sent through the brain, causing a small grand mal seizure

pt is on propofol and given supplemental O2

used when meds are not working for pt

who does electroconvulsive therapy benefit

MDD pts

schizophrenic pts

bipolar manic pts

seizure meds before electroconvulsive therapy

do not let pt take their seizure meds before electroconvulsive therapy

LOC after electroconvulsive therapy

pt may be a little confused after electroconvulsive therapy

who can give electroconvulsive therapy

nurses who are certified in giving it

how does electroconvulsive therapy work

pt given 2-3 treatments per week

6-12 treatments total

what is needed before electroconvulsive therapy

the pt's consent

transcranial magnetic stimulation

an MRI stimulates parts of the cerebral cotex

vagus nerve stimulation

electrical nerv stimulation through the vagus nerve to the brain

an implant under the skin on chest

what doesvagus nerve stimulation do

increases neurotransmitters and enhances medications

vagus nerve stimulation complications

causes voice changes like hoarseness and pitch changes

causes pt to cough everything out of their mouth during stimulation

bipolar disorder

recurrent episodes of mania and depression

periods of normal functioning alternate with periods of illness

how to tell the difference between schizophrenia and bipolar manic

schizophrenia has + and - symptoms appearing at the same time

bipolar disorder has either + or - symptoms appearing at once, depending on if the pt is in mania or depression

mania

abnormal elevated mood (expansive, irritable)

pt will be hospitalized during mania episodes

episodes last 1 week

hypomania

less severe episode of mania

lasts 4+ days

pt will NOT be hospitalized during hypomania episode

rapid cycling

4+ episodes of hypomania or acute mania within 1 year

increase recurrence rate and resilience to treatment

bipolar causes

genetics

physiological

environment

what can cause a bipolar pt to relapse into mania

food - sugar, caffiene, stimulants

environment - high stimulating environments

types of bipolar disorder

bipolar 1

bipolar 2

cyclo-thymic disorder

bipolar 1

at least 1 episode of mania alternating with major depression

bipolar 2

1+ hypomania episode with major depression

cyclo-thymic disorder

2+ years hypomanic behavior that do not meet criteria for hypomanic episode alternative with minor depressive episodes

phases of bipolar disorder

acute

continuation phase

mainteneance phase

acute bipolar phase

acute mania

pt will be hospitalized

risk of exhaustion, malnutrition, and dehydration

- pt does not stop to eat and drink, always on the go

continuation bipolar phase

remission of manifestations

treatment lasts 4 - 9 months

educate pt about medication compliance

maintenance bipolar phase

increase ability to function

goal is to prevent relapse

- tell pt to avoid things that cause mania or depression (stimulants, etc.)

bipolar assessment

they handle criticism poorly

hyper verbal tendencies when manic

hypo verbal tendencies with depressed

flight of ideas

percusatory delusions

hallucinations

demanding and manipulative behavior

short attention span

attention seeking

- may dress provocatively in bright colors

bad ADLs

lots of physical activity may lead to exhaustion

meds for bipolar disorder

mood stabilizers

antiepileptic meds

antipsychotics

anxiolytics

antidepressants

lithium

mood stabilizer for bipolar disorder

how does lithium work

lowers dopamine and GABA

labs to monitor for lithium

renal labs

- BUN

- creatinine

- GFR

Na levels

lithium levels

why do we need to monitor Na when using lithium

the kidneys process lithium and sodium in a similar way

a significant change in the body's sodium levels can directly impact the concentration of lithium, leading to either therapeutic failure or lithium toxicity

basically a low-sodium diet can cause the kidneys to reabsorb more lithium, significantly increasing its levels in the blood and risking toxicity

lithium levels

less than 1.5 is good

1.5 - 2.5 is toxic

over 2.5 is lethal

what to do if lithium level is between 1.5 - 2.5

hold the lithium med

call the MD

pt education with lithium

increase fluids

- buffer for kidneys, helps them filter out lithium

increase sodium

NSAIDs with lithium

cant take NSAIDs with lithium

too nephrotoxic

lithium side effects / considerations

transient (coming and going) GI issues

polyuria

wt changes

- from increased fluids and sodium

antiepileptic mood stabilizing meds

carbamazepine

valproic acid / valproate

lamotrigine

how do antiepileptics work for bipolar disorder

they decrease CNS excitation

treats mixed mania and rapid cycling bipolar

carbamazepine side effects

CNS problems (transient)

blood problems

- anemia

- thrombocytosis

- glucopenia

- monitor for bleeding, bruising, and infection

steven-johnson syndrome

steven johnsons syndrome

a severe and potentially life-threatening skin reaction

fever and flu-like symptoms

progresses to bright, red blisters of the skin that spread rapidly

may lead to organ failure and death

carbamazepine interactions

oral contraceptives

grapefruit juice

- will affect metabolism of med causing it to randomly increase or decrease

valproic acid side effects

GI issues

- nausea, vomiting, indigestion

- take with foods

hepatotoxic

- lab draws

pancreatitis

thrombocytopenia

lab draws for valproic acid

draw VPA (valproic acid) level after 12 hours then again after 24 hours when first starting med

liver panels Q2 months

valproic acid interactions

CANT use with anticonvulsants

- causes VPA levels to fluctuate

what is valproic acid commonly used for

people with autism

lamotrigine side effects

CNS

- blurred vision, dizziness

stephen johnson syndrome

lamotrigine interactions

DO NOT USE with valproic acid

- does metabolize meds therefore causes meds to last longer in system

oral contraceptives

nursing care for those with bipolar disorder

prevent harm and exhaustion

set firm limits with the pt

provide expectations