MYTHS ABOUT BIPOLAR DISORDER (BD) can stand in the way of providing
appropriate care for persons who have this condition. One myth—that those with BD should
be able to control it by will alone—may prevent sufferers from adhering to therapy or from seeking care in the first place. This article helps you improve patient outcomes by explaining what BD is, how it manifests, and how it’s managed.

The sixth leading cause of disability in the world, BD is an episodic, chronic illness affecting approximately 5.7 million adult Americans. It’s marked by extreme changes in mood, thought, behavior, and energy level. Mood swings can vary in intensity, length, and the degree to which they interfere with functioning. Severe mood swings can last weeks or months and may severely disrupt the person’s life.

BD occurs in all races, ethnic groups, and social classes. Although it affects males and females equally, males tend to have an earlier onset. BD reduces life expectancy by 9.2 years, with up to 33% of sufferers attempting suicide and 15% completing it.

About 69% of persons with BD are misdiagnosed, delaying proper treatment 5 to 10 years. The most
common misdiagnosis is major depressive disorder—probably because most people with BD seek help
when they’re so depressed they can’t function, not when they’re having a manic episode and believe
they can accomplish anything.

Causes

Research shows that in persons with BD, neuropathologic changes occur
in the amygdala, a structure deep within the brain’s temporal lobes
that plays a key role in memory and processing of emotions. Studies also
reveal abnormal levels of the neurotransmitters norepinephrine, serotonin,
dopamine, glutamate, and gamma-aminobutyric acid (GABA)
in this area. Norepinephrine plays
a role in mood regulation, arousal,
and memory; dopamine acts as the
brain’s natural reward system. Serotonin
is involved in mood regulation,
anxiety, pain perception, appetite,
sleep, sexual behavior, and
impulsive behavior. Glutamate is the
primary excitatory neurotransmitter;
GABA, the primary inhibitory transmitter.
Evidence suggests that levels
of norepinephrine, serotonin, and
dopamine are decreased in people
with depression. Increasing GABA
levels and decreasing glutamate levels
can improve or stabilize mood.

Research with twins suggests BD
is inheritable: When one twin has
BD, the other is at high risk for developing
it. Also, more than 66% of
people with BD have a first-degree
relative who suffers from BD or a
major depressive disorder. (See Risk
factors for bipolar disorder by clicking the PDF icon above.)

Signs and symptoms

People with BD frequently report
experiencing highs (mania) and
lows (depression). Men with BD are
more likely to present with a manic
episode, whereas women are more
likely to present with a depressive
episode. (See Two types of bipolar
disorder by clicking the PDF icon above.)

A manic episode is a distinct period
of abnormally elevated, expansive,
euphoric, or irritable and agitated
mood that lasts at least a week
and severely impairs the ability to
function. During this time, the person
may think he or she is functioning
exceptionally well. According
to criteria from the Diagnostic
and Statistical Manual of Mental
Disorders (4th edition, text revision;
DSM-IV-TR), at least three of the
following must be present to qualify
as a manic episode:

• inflated self-esteem, extreme optimism
  and self-confidence, excessive
  irritability, or aggressive
  behavior
• decreased need for sleep
• increased talkativeness or pressure to keep talking
• flight of ideas or racing thoughts
• distractibility
• increased goal-directed activity
  or psychomotor agitation
• excessive involvement in pleasurable
  activities likely to cause
  negative consequences, such as
  spending sprees and sexual indiscretions.

Untreated, a manic episode can
last 3 to 6 months. Psychotic signs
and symptoms, including hallucinations
and delusions, may occur and
require hospitalization.

Hypomanic episodes

A hypomanic episode is an abnormally
elevated, expansive, or irritable
mood lasting at least 4 days that
doesn’t severely impair the ability
to function. It’s marked by three or
more of the features listed above
for manic episodes. During this
time, the person may appear extremely
happy and believe he or
she is functioning well, with high
productivity and creativity. No psychotic
features are present and hospitalization
rarely is required.

Diagnosis

Diagnosis rests on a thorough history
and exclusion of other conditions.
Depending on symptom
severity, the patient’s perceptions
may be incomplete or inaccurate.
You may need to interview family
members or significant others to
obtain a clearer picture of the patient’s
signs and symptoms, medical
history (including previous bipolar
episodes), and family history.

Many clinicians administer the
Mood Disorder Questionnaire, a
short self-report instrument, to
screen for BD and augment a complete
mental status assessment. This
tool asks whether the patient has
experienced symptoms, if multiple
symptoms have occurred during the
same time period, and how much
of a problem the symptoms have
caused. The patient’s responses
help guide treatment.

Pharmacologic treatment

Acute treatment focuses on decreasing
symptoms and restoring the patient’s
coping and functioning ability.
After stabilization, the goal is to prevent
relapse and limit symptom duration and severity. The odds of a relapse
are 85% to 95%, with medication
noncompliance a major cause.

Mood-stabilizing drugs are the
mainstay of treatment. Algorithms
developed from randomized controlled
drug trials and expert opinion
guide treatment. Severe manic or
mixed states typically call for either
lithium (an antimanic agent) or valproate
(an anticonvulsant), plus an
antipsychotic. For less severe manic
episodes, lithium, valproate, or an
antipsychotic may be used alone.

Anticonvulsants

Anticonvulsants, such as valproate,
carbamazepine, and lamotrigine,
are first-line drugs used alone or in
combination with each other or
second-generation antipsychotics,
because of their mood-regulating
efficacy (especially in mania). Valproate
and carbamazepine are recommended
for mania; both require
regular monitoring of plasma drug
levels and liver function. Carbamazepine
must be used cautiously
because it can cause agranulocytosis
and anemia; oxcarbazepine can
be substituted if needed.

Benzodiazepines are used to manage
BD in patients with severe anxiety
or insomnia. Some experts recommend
clonazepam for its anticonvulsant
and GABA-enhancing effects.

Lithium

Lithium is still recommended for BD,
although it’s less commonly used today
than in the past because of its extensive
adverse effects, such as polydipsia,
polyuria, weight gain, hypothyroidism,
acne, and toxicity risk.

Drug therapy for BD with depression

Although not used as often, lithium
remains a first-line treatment for BD
with major depressive episodes. Lamotrigine
is also a first-line drug in this
situation. When used alone, antidepressants
can trigger a manic episode
and aren’t recommended unless a mood regulator also is prescribed.

Patients with BD plus depression
and psychotic symptoms typically
receive antipsychotics. Because lithium
and anticonvulsants take longer
than 1 week to treat mania, antipsychotics
typically are given to manage
acute mania symptoms until
mood regulators reach effective plasma
levels. The second-generation
antipsychotics olanzapine, risperidone,
quetiapine, ziprasidone, and
aripiprazole are approved as monotherapy
for BD in patients with hallucinations
and delusions. But some
clinicians regard several atypical antipsychotics
(especially olanzapine)
as second-line choices because of
the risk of weight gain, dyslipidemia,
and diabetes mellitus type 2.

Electroconvulsive therapy

Research shows electroconvulsive
therapy (ECT), which causes
seizures that affect mood regulation,
is effective for patients with
treatment-resistant BD. Typically,
the patient receives 6 to 10 treatments
over several weeks. ECT is considered safe and effective today because it’s done with anesthesia in a controlled setting. Adverse effects, such as headache and memory loss,
subside once treatment ends.

Nonpharmacologic treatment

Although many BD patients take
multiple medications, they should
receive nonpharmacologic treatments
simultaneously for optimal stabilization and relapse prevention.
BD patients can benefit from:

• psychosocial therapy and psychotherapy
  addressing illness
  management
• early relapse detection
• reinforcement of medication
  adherence
• lifestyle changes that enhance
  coping ability through realistic
  expectations and modifying
  behaviors
• support group work or individual
  counseling.

Adequate sleep is important to stabilization; so are realistic expectations.
The clinician should create an action plan to use when early
relapse symptoms occur.

Cognitive-behavioral therapy, interpersonal
relationship therapy, psychodynamic
therapy, family therapy,
and group therapy (including psychoeducational
therapy) may be used
alone or in combination. Cognitivebehavioral
therapies focus on changing
negative thought processes.
Psycho-educational therapy is a type
of group therapy that combines support
and self-help strategies. The
most common type of group facilitated
by nurses, psycho-educational
therapy starts in the acute setting
and continues during maintenance.
Priorities for this therapy include:

• establishing a stable sleep pattern
• developing a regular activity
  pattern
• avoiding alcohol and other substances
• asking for and using support
  from family and friends
• decreasing stress at work and at
  home
• identifying early warning signs
• developing problem-solving and
  emotional tolerance and regulation
  skills.

Patient needs, cost, and the expected
duration of therapy influence
the type of therapy selected. Factors
that may increase treatment success
include a good patient-provider relationship,
a supportive environment,
medication adherence, and the patient’s
willingness to explore and try
new coping strategies.

Nursing management

BD can be managed in both inpatient
and community settings.
Acute short-term treatment goals differ
from long-term maintenance
goals. For acute short-term treatment,
the goals are stabilization and
safety; for long-term maintenance,
goals include preventing relapse and
limiting the duration and severity of
manic or depressive episodes. To
ensure continuity of care, make sure
you understand treatment priorities
and goals in both settings. (See Nursing management priorities by clicking the PDf icon above.)

For inpatient treatment, signs and
symptoms of depression or mania determine
the goals and focus of management. Safety is the first priority.
Patients with depression are at high
risk for self-harm. Those admitted
with a manic episode may show signs
and symptoms of irritability, delusions,
impulsivity, and anger; they
also are at risk for harming themselves
or others. Medications help stabilize
the patient, allowing effective
implementation of other treatments.

For outpatient management,
goals include reestablishing the patient’s
previous functioning level,
identifying triggers, preventing relapse
or reducing its severity, and
limiting the duration of future episodes.
In community settings, monitor
the patient’s treatment responses
over time.

Patient teaching

Provide education about BD to the
patient and family members, emphasizing
the need for medication adherence
and effective coping and
lifestyle changes. If your patient is
taking lamotrigine, be aware that a
serious rash, such as Stevens-Johnson
syndrome (indicated by involvement
of at least one mucous membrane),
can occur at low dosages
and may arise early in treatment.
Widespread rashes involving the mucous
membranes—especially with
fever or sore throat—demand intervention.
Teach patients to contact
their healthcare provider if such a
rash develops.

Rising to the challenge

BD patients experience a wide
range of signs and symptoms that
affect their daily functioning. Healthcare
providers must understand the
disorder, patient and family perceptions,
and management options. Providing
supportive, holistic nursing
care helps dispel myths and enhances
patients’ quality of life.

Selected references

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders.
4th ed., text revision. Washington, D.C.: American Psychiatric Association; 2000.

Depression and Bipolar Support Alliance. Bipolar disorder. Updated February 5, 2009.
http://www.dbsalliance.org/site/PageServer?pagename=education_bipolar. Accessed June 6, 2011.

Hirschfeld R. Guideline watch: Practice guidelines for the treatment of patients with bipolar disorder. In: American Psychiatric Association Practice Guidelines for the Treatment of Psychiatric Disorders: Compendium 2006. Washington, DC: American Psychiatric Association; 2006:841-906.

National Alliance on Mental Illness. Bipolar disorder. www.nami.org/Template.cfm?Section
=By_Illness&Template=/TaggedPage/TaggedPageDisplay.cfm&TPLID=54&ContentID=23037. Accessed June 6, 2011.

The authors teach at Ball State University School of Nursing in Muncie, Indiana. AnnWieseke and Diana Bantz are associate professors. At the time this article was written, Deborah May was an assistant professor at Ball State University School of Nursing.