Bipolar Disorder

(Manic Depression)
Trevor Gump
 What is Bipolar Disorder?
• Mental disorder
• Causes drastic changes in mood, energy levels, concentration, and
ability to carryout ADLs.
• Periods of mania (up) and depression (down).
 Definitions
• Mania: Period when patient experiences feelings of elation, increased mood,
irritability.
• Characteristics: wired/jumpy behavior, loss of appetite, fast speech and
frequent changes on topic, reckless behavior, lack of sleep, racing thoughts,
feeling of higher importance/talent/power
• Depression: period of low mood, lack of interest, and overall “down” mood
• Characteristics: sleep disturbances, feelings of hopelessness, inability to
complete simple tasks, lack of interest in usual activities, decreased or absent
sex drive, anhedonia (inability to feel pleasure), and suicidal thought and
ideations.
• Hypomania: less intense manic episodes lasting no more than four days, that
allow patent to feel good, complete ADLs, basically it is a significant positive shift
in mood that others tend to notice rather than the patient themselves.
 Types of Bipolar Disorder
• Bipolar Disorder I: Periods of mania lasting longer than 7 days
followed by at least 2 weeks of depression.
• Bipolar Disorder II: Noticeable patterns of depressive episodes and
hypomanic episodes
• Cyclothymic Disorder (Cyclothymia): frequent hypomanic episodes
followed by depressive symptoms lasting longer than two years, 1
year in children and teens.
• Often mistakenly diagnosed as major depressive disorder
 What causes Bipolar Disorder?
• The exact cause of Bipolar Disorder is ambiguous, but there seem to
be many probable causes.

• Genetics: it is believed that 80-90% of individuals diagnosed with

Bipolar Disorder have a family member diagnosed with the condition.
• More research is needed to conclude which genes exactly are involved, but it
is believed many are involved.
• Brain Structure: changes to the structure of the brain will be
discussed on the next slide.
 What exactly is going on in the brain?
• Structurally: postmortem studies on individuals who suffered from bipolar
disorder there are noted structural changes in the prefrontal cortex as well
as decreased grey matter.
• Bipolar mania imaging shows changes in blood flow to the orbitofrontal
cortex and increased metabolism
• Bipolar depressive imaging shows changes in prefrontal and subcortical
activity of the brain. Specifically, decreased metabolism in the prefrontal
cortical metabolism and an increase in subcortical metabolism compared to
controls
• Dopamine, Norepinephrine, Serotonin, GABA, and Glutamate are all
effected by Bipolar Disorder
 Pharmacotherapy
• Mood Stabilizers: Lithium
• Oldest medication used, can build up in blood stream
• Can suppress thyroid function  treated with Synthroid
• Antidepressants: Cymbalta, Zoloft
• Used alongside mood stabilizers to control depressive episodes
• SE: nausea, vomiting, dry mouth, constipation
• Antipsychotics: risperidone, clozapine
• Effective at preventing manic episodes, used with antidepressants
• SE: significant decrease in metabolism  weight gain
• Antianxiety: benzodiazapines
• Anticonvulsants: Depakote*
• Commonly used to treat seizure disorders but has off label uses to slow brain activity during manic
episodes.
 General Side Effects of Pharmacotherapy
• Sleep disturbances
• Vivid dreams/nightmares
• Irritability/aggression
• Decrease libido
• Nausea, vomiting, diarrhea
• Weight changes (gain or loss)
• Increased depressive state
• Suicidal ideation
 Medication Considerations
• Avoid drugs and alcohol while taking medications for bipolar disorder
• Maintain regular medication schedule
• Sudden discontinuation of medications results in rebound effects
• Report new side effects to doctor as soon as possible
 Nonpharmaceutical Treatment
• Psychotherapy: regular talk therapy sessions with a therapist or counselor.
• Interpersonal and social rhythm therapy (IPSRT): psychotherapy designed to
improve mood by understand that patient’s unique social and biological
cycled
• Electroconvulsive Therapy (ECT): delivered under general anesthesia over
the course of several weeks. Electrical impulses are applied to the brain.
Reserved for cases where medications do not work or when a rapid response
is needed (high risk of suicide)
• Exercise: aerobic and anaerobic exercises are beneficial
• Maintenance of a life chart tracking moods, feelings, and concerns over time.
 Levels to Monitor
• Thyroid levels (T4 and TSH) are commonly pulled to rule out
hypo/hyperthyroidism as well as monitoring function with
antipsychotics.
• T4: 5.4 – 11.5
• TSH: 0.4 – 4.0
• Lithium levels are monitored in the blood to avoid toxicity
• Therapeutic level: 0.5 – 1.2 mmol/L (trough)
• Toxic Level: >1.6mmol/L
 Bipolar Disorder’s friends (comorbidities)
• Anxiety Disorders
• Substance Abuse Disorder
• Alcohol and drug use
• Attention Deficit Hyperactivity Disorder (ADHD)
• Eating Disorders (most commonly binge eating disorder and bulimia)
Attention-Deficit/Hyperactivity Disorder in Adults With Bipolar Disorder or Major
Depressive Disorder: Results From the International Mood Disorders Collaborative
Project

• n=399
• Participants collected from International Mood Disorders Collaborate Project
• Patients evaluated and diagnosed based on DSM-IV

• Major Depressive Disorder: 5.4% diagnosed with lifetime ADHD

• Bipolar Disorder: 17.6% diagnosed with lifetime ADHD

• Conclusion: ADHD is commonly diagnosed in those who suffer from MDD or

Bipolar Disorder. It causes increased illness burden and increases complexity.
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2947541/
 Sleep matters: Sleep functioning and course
of illness in bipolar disorder
• N=468
• Purpose: investigate the effects of total sleep time and sleep
variabilities effects on bipolar disorder symptom presentation
• Methods: Sleep pattens of patients with DSM-IV Bipolar patients were
observed
• Results: Shorter TST caused increases in mania severity and an
increased SV triggers more severe mania and depression symptoms
over a 12-month period
https://www.sciencedirect.com/science/article/pii/S016503271100262X?casa_token=jhT3MtYInrAAAAAA:_wcVEqZMeh4qRj5tRC3yk1E3rxtcRoHjGB3J877-rHO-19nZIctMiL89bSY6Db
nQKJeq5Ir6Hic
The Role of Electroconvulsive Therapy (ECT) in Bipolar Disorder: Effectiveness in
522 Patients with Bipolar Depression, Mixed-state, Mania and Catatonic Features

• n= 522
• Participants with medication resistant bipolar disorder were evaluated for before
and after electroconvulsive therapy.
• 344 (68.8%) patients reported less severe symptoms and having a positive
response to the therapy
• BD: 68.1%, mixed state: 72.9%, mania 75.0%, and catatonic features 80.8%
• 156 (31.2%) of participants did not respond to therapy
• Conclusion: ECT proves to be an effective mode of therapy for the treatment of
patients with bipolar disorder

• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5405614/
 Impaired Verbal Communication

Nursing Interventions Goals

1. Use therapeutic communication 1. Patient will effectively use alternative
techniques methods of communication within 8
2. Be persistent in deciphering what the hours.
client is saying, do not pretend to 2. Patient will express desire for social
understand when the message is interactions within 1 week.
unclear
3. Determine patients own perception of
communication difficulties and
potential solutions when possible
 Fatigue

Nursing Interventions Goals

1. Assess severity of fatigue on a scale of 1. Patient will seek balance between
0-10, frequency of fatigue, and work, exercise, leisure, rest, and
activities/symptoms associated with maintenance within one week
fatigue 2. Patient will identify ways to cope
2. Evaluate adequacy of nutrition and effectively and use appropriate
sleep hygiene support systems within 48 hours.
3. Review comorbid conditions (Mania)
that may be causing the fatigue
 Risk Prone Health Behavior

Nursing Interventions Goals

1. Assess patient’s definition of health
and wellness and major barriers to
health and wellness
2. Use open ended questions to allow
the client free expression
3. Manipulate the environment to
decrease stress
1. Client will request assistance in
altering behaviors to adapt to change
within 1 week
2. Patient will report and/or demonstrate
behaviors mutually agreed upon by
the nurse as evidence of positive
adaptation within 2 weeks
 Ineffective Health Maintenance

Nursing interventions Goals

1. Assess the patient’s feelings, values, 1. Client will follow mutually agreed
and reasons for not following the upon health care maintenance plan
prescribed plan of care. within 1 week
2. Refer client to appropriate services as 2. Patient will meet goals for health care
needed maintenance within 2 days.
3. Assist the patient in reducing stress
 Insomnia
Nursing Interventions Goals
1. Obtain a sleep history including the 1. Patient will verbalize plan to
amount of time needed to initiate implement sleep-promoting routines
sleep, duration of awakenings during within 96 hours.
first sleep onset, total nighttime sleep 2. Patient will wake up less frequently
amounts, and satisfaction with sleep during night a minimum of 4 nights
amounts. out of seven within 3 weeks.
2. Avoid negative associations with
ability to sleep
3. If feasible, have the client arise from
bed to participate in calming activities
whenever anxious about failure to fall
asleep.
 References
• https://www.ipsrt.org/
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2574701/
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2947541/
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5405614/
• https://www.nimh.nih.gov/health/topics/bipolar-disorder/index.shtml
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3181872/#:~:text=In%20bipolar%20disorder%2C%20structural%20brain,family%20history
%20of%20affective%20disorder
• https://www.psychiatry.org/patients-families/bipolar-disorders/what-are-bipolar-disorders
• https://www.psycom.net/bipolar-disorder-medications
• https://www.psycom.net/bipolar-medications-depakote-divalproex-sodium/#:~:text=Depakote%20is%20a%20medication%20known,manic
%20symptoms%20of%20bipolar%20disorder&text=What%20is%20Depakote%3F,seizures%20and%20prevent%20migraine%20headaches
.
• https://www.sciencedirect.com/science/article/pii/S016503271100262X?casa_token=jhT3MtYInrAAAAAA:_wcVEqZMeh4qRj5tRC3yk1E3rxt
cRoHjGB3J877-rHO-19nZIctMiL89bSY6DbnQKJeq5Ir6Hic

• https://screening.mhanational.org/content/i-think-my-medication-making-me-feel-worse