Bipolar disorder is a complex and challenging brain disorder in which moods range from periods of mania followed by episodes of depression, from sadness to euphoria (Ferri, 2018). Bipolar disorder used to be called manic-depressive because of these two symptoms.
During a manic phase you will usually see a decreased need for sleep, an inflated self-esteem, pressured or fast speech patterns, flight of ideas, racing thoughts, distractibility, risky behaviors or an increase in goal-directed activities (Ferri, 2018). It is possible for individuals to develop delusions or hallucinations during the manic phase (INSA, 2017). Followed by the manic phase will be a depressive episode. During the depressive episode individuals will feel feelings of worthlessness, thoughts of suicide, disinterest in work, family, or friends (INSA, 2017). It is during the depressive phase that most people seek medical assistance.
Unfortunately, the management of the disease has no specific combination of psychosocial and medication regime that works well for everyone’s mood instability. So, therefore, the right combination to manage a particular patient’s mood instability takes time and can change over time due to the patient’s noncompliance with medication and frustration with treatment. However, as with any chronic health condition the bipolar patient has to learn how to be compliant and make lifestyle changes to manage symptoms.
Prevalence and Incidence
The prevalence accounts for about 2.6% of the adult population of these nearly 83% of the adult United States population is considered severe. Some data reports that females are at a higher risk for depression and rapid mood swings while males have a higher risk for mania (ISNA, 2017). The prevalence of bipolar disorder among U.S. adults aged 18 or older an estimated 2.8% of U.S. adults had bipolar disorder in the past year, and adolescents aged 13-18 are estimated at 2.9% of having bipolar disorder, with 2.6% considered severe (NIH, 2017). About 10% of patients who attend primary care setting are at risk for bipolar, and 25% of the more difficult depression cases are likely to be undiagnosed as a bipolar disorder (Epocrates, 2017).
Pathophysiology
The pathophysiology of the bipolar affective disorder, or manic-depressive illness, has not been determined, and no biologic markers are identified to correspond with the disease state. However, twin, family, and adoption studies all indicate that bipolar disorder has a significant genetic component and stressors or triggers that contribute to the phenotypic expression of the underlying mood shifts. In like manner, the structural finding with the use of magnetic resonance imaging (MRI) shows abnormal brain regions, neurochemical changes that regulate mood shifts and increased periventricular white matter hyperintensities compared with healthy individuals (Epocrates, 2017).
There are different types of bipolar disorder with the most common two being bipolar disorder I and bipolar disorder II. Both types have similar symptoms, but the length and acuity of symptoms vary.
- Bipolar disorder I has more intense episodes of mania and depression. Mania can last for at least a week followed by severe depression for up to two weeks (INSA, 2017).
- For bipolar disorder I they must have at least a week of abnormally elevated behaviors that cause impairment in functioning (Ferri, 2018).
- Bipolar disorder II is categorized as being hypomania followed by depression. Hypomania is less intense than mania but is still concerning.
- The hypomania seen in bipolar disorder II individuals must last four days, change their mood and functioning, and are clearly different than their depressed state (Ferri, 2018).
***It is during hypomanic or manic episodes that many individuals with bipolar disorder stop taking their medications (INSA, 2017). ***
Physical Assessment and Examination
Bipolar disorder is usually diagnosed during adolescents and more than half of adults had their first bipolar episode by at 18 (Benarous, Consoli, Milhiet, & Cohen, 2016). Bipolar disorder is the fourth leading cause of disability in 10-24 year old worldwide (Benarous, Consoli, Milhiet, & Cohen, 2016). There is no distinct cause for bipolar disorder, but genetics, environment, endophenotypes, and specific biomarkers can influence a person’s chance of developing bipolar disorder (Benarous, Consoli, Milhiet, & Cohen, 2016).
The diagnosis of bipolar disorder typically occurs when an individual seeks help for their depressed state. To diagnosing a bipolar disorder, there should be a thorough clinical assessment of the patient psycho-social status, medical and psychiatric commodities, current and past medications as well as medication compliance, and substance use. It is important to talk to patients to determine their mood and behaviors before they started feeling depressed.
A detailed review of symptoms, symptom severity, and their effects on daily functioning in combination with the use of a standard tool such as the young mania scale rating to assess the severity of the manic episode. Associated symptoms for manic or hypomanic episodes are grandiosity, diminished need for sleep, excessive talking, racing thoughts, distractibility, increased level of goal-focused activity at home, at work, or sexually extreme pleasurable events, often with painful consequences. On the other hand with significant depression the episodes last two weeks, the person experiences depressed mood that manifests as a loss of pleasure or interest. Included is weight loss or weight gain, hypersomnia or insomnia, psychomotor retardation or agitation, Loss of energy, feelings of worthlessness or excessive guilt, decreased concentration or marked indecisiveness and preoccupation with suicide (Soreff, 2017).
It is important to rule out other things that may be causing the symptoms like medications, dementia, hyperthyroidism, or stroke. This can be done by getting an H&P, mental status exam, Mood Disorder Questionnaire, and Composite International Diagnosis Interview (Ferri, 2018).
Treatment Plan
The treatment plan is based on the severity of the disorder and when patients are severely affected without insight into their illness may require urgent psychiatric hospitalization to assure their safety and that of others.
- With a patient who is not rapidly cycling and is non-pregnant, the mania or hypomania with agitation treatment is an intramuscular injection of a neuroleptic or benzodiazepine and if no agitation with hypomania, mild mania or moderate mania to severe, monotherapy mood stabilizers and atypical antipsychotics are recommended. However, in acute bipolar depression the support for antidepressant as an effective treatment lacks controlled studies so, therefore, a combination of olanzapine/fluoxetine is used. The rapid cycling non-pregnant patients require deliberate planning, and patience, so the focus is on mood stabilizers and removing exacerbation factors like illicit drugs, alcohol, stimulates.
- When pregnant patients have been diagnosed with the disorder, a referral to a psychiatrist and obstetrician is implemented. The test included in the examination is a valid questionnaire that identifies mental disorders or bipolar depression along with obtaining CBC, TFTs, serum vitamin D, and a toxicology screen to rule out other causes of the mood symptoms.
Follow up of bipolar disorder requires lifelong treatment, management with frequent monitoring, rating scales of mood and health questionnaire to measure the response to depression as well as monitoring the patients weekly who are discharged from the hospital.
Treatment for bipolar disorder usually combines therapies along with medications. Cognitive-behavioral therapy, psychosocial treatment, or psychoeducation can help individuals understand their disease and ways to function in daily life (ISNA, 2017). Mood stabilizers, antipsychotics, and antidepressants are often prescribed to help with symptoms. Lithium is the first line for acute mania but requires blood monitoring to ensure proper levels (ISNA, 2017). Valporate, or lamotrigine may be prescribed as well. The main side effects of these medications include GI problems, hair loss, motor problems, cognitive impairments, weight gain, sexual issues, skin eruptions or visual disturbances (INSA, 2017). As mentioned above, combining a mood stabilizer with an antipsychotic can help to stabilize acute mania such as benzodiazepine, lorazepam, or clonazepam (Ferri, 2018). Antipsychotics are also used when a depressive mood begins and are tapered down when mood stabilizes.
Patient Education
Education should be provided to the family or friends to alert the patient and the clinician, should warning signs of relapse emerge. The patient should work with their health provider to identify individual patterns of relapse, recurrence, and changes in sleep to prevent a total decline. Also, the patients should be encouraged to speak openly about their experience of bipolar illness, feelings of stigma, and any adverse effects of the medications that may threaten adherence and sustained mood stability. Avoidance of situations or stressors known to trigger strong, negative emotions, based on their own experience and unhealthy relationships, poor living conditions, or stressful jobs may easily overwhelm their fragile state of recovery. Some patients need reminders or pill-boxes, a scheduled sleep routine, proper eating, and moderate exercise which should become a regular part of daily living. Other resources that should be provided by the healthcare provider is community organizations, and patient advocacy groups such as the National Alliance for Mental Illness or the Depression Bipolar Support Alliance, both organizations can foster recovery for the patient and their family (Epocrates, 2017). In conclusion, treatment and management of bipolar disorder are challenging because of the recurrent nature of the condition, diagnosing the disease accurately and the safety factors for the patient and others.
The long term goal is to prevent further episodes or re-occurrence. Mood stabilizers should be taken daily, even when they are feeling better. Safety is an important issue and needs to be addressed. It is not uncommon for individuals with bipolar to use substances and should be screened for any drugs or alcohol that maybe in their system. If the patient is extremely manic or depressed it is important to refer them on to see a psychiatrist for medication management and treatment.
References:
Benarous, X., Consoli, A., Milhiet, V., Cohen, D. (2016). Early interventions for youths at high risk for bipolar disorder: A developmental approach. European Child and Adolescent Psychiatry, 25, 217-233.
Bipolar disorder (2017) National institute of mental health. Retrieved https://www.nimh. nih.gov/health/statistics/bipolar-disorder.shtml
Bipolar disorder in adults-Epocrates Online (2017). Retrieved https://online.epocrates.com/
Ferri, F. (2018). Fred’s Clinical Advisor 2018. Elsevier: Philadelphia, PA.
Gooding, C. & Wolford, K. (2013) Bipolar disorder. Retrieved https://eds-a-ebscohost-com.lib.kaplan.edu/eds/detail/detail?vid=1&sid=3dca9565-038c-4471-b87d-73a81e5b5ded%40sessionmgr4010&bdata=JnNpd
ISNA Bulletin. (2017). Bipolar disorder: Implications for nursing practice. Indiana State Nurses Association 43,(4), 12-15.
Soreff, S. (2017). Bipolar affective disorder clinical presentation. Retrieved https://emedicine. medscape.com/article/286342-clinical
