Assessing and Treating Patients With Bipolar Disorder

Assessing and Treating Patients With Bipolar Disorder

Bipolar disorder is one of the mental health problems with considerable impacts on the global population. Bipolar disorder patients experience distressing symptoms that affect their health, well-being, and functioning. Healthcare providers must adopt treatment interventions that address the prioritized health needs of their patients and promote safety, quality, and efficiency outcomes. Evidence-based data inform the care interventions for patients with bipolar disorder. Therefore, this essay examines the prevalence and neurobiology of bipolar I disorder, its differences from bipolar II disorder, special considerations, clinical practice guidelines, side effects, and monitoring patients prescribed different treatments.

Prevalence and Neurobiology of Bipolar I Disorder

Bipolar I disorder is the selected disorder for analysis in this paper. Bipolar I disorder is one of the subtypes of bipolar disorder. Patients who are affected by bipolar I disorder experience episodes of neuropsychological deficits, severe mood disturbances, functioning impairment, and physiological changes. Data obtained from epidemiological studies reveal that the lifetime prevalence of bipolar I disorder is about 1% in the entire population. The overall lifetime prevalence of an individual being affected by bipolar I disorder is 0.6% and 2.4% for bipolar spectrum disorders. When compared to other bipolar spectrum disorders, bipolar I disorder has the lowest prevalence of all (McIntyre et al., 2020). However, the United States of America has a 1% higher prevalence rate of bipolar disorder when compared to other developed countries.

Bipolar I disorder has a neurobiological basis. Studies agree that an interaction between genetic factors and environmental factors precipitate bipolar I disorder. Environmental factors such as traumatic events and stress trigger the development of bipolar I disorder in individuals with a genetic predisposition. Besides the interaction, dysfunction in different intracellular cascades in the brain also contributes to bipolar disorder. This includes an imbalance in the different neurotransmitters that regulate emotions in the brain (Scaini et al., 2020). Mitochondrial dysfunction and oxidative stress also increase the risk of bipolar I disorder. The dysfunction and stress cause considerable impairment in neuronal plasticity, hence, the damage and loss of brain tissue. Studies have also revealed that patients with bipolar disorders have altered peripheral biomarkers related to inflammation, neurotrophins, hormones, and oxidative stress (Young & Juruena, 2021). The alteration explains the physiological, emotional, immunological, and functional impairments seen in patients with bipolar disorders.

Differences Between Bipolar I and Bipolar II Disorders

Bipolar I disorder differs from bipolar II disorder. According to DSM-5, a diagnosis of bipolar I disorder is reached if a patient presents to the hospital with symptoms of a manic episode. The symptoms include abnormally and persistently elevated irritable or expansive mood and abnormal engagement in goal-directed activity with high energy levels lasting at least a week. The symptoms persist most days almost every day (McIntyre et al., 2020). Patients have symptoms such as inflated self-esteem, insomnia, talkativeness, flight of ideas, easy distractibility, and increased involvement in harmful activities during this period.

Patients with bipolar II disorder present to the hospital with symptoms that meet at least a major depressive and hypomanic episode. They also do not have a history of manic episodes. Hypomania and depressive episodes cannot be attributed to other causes such as schizophrenia, schizoaffective disorder, or delusional disorder among other mental health problems. The symptoms of hypomania episodes are similar to those of mania in bipolar I disorder. However, a difference lies in their duration. In bipolar II disorder, the hypomania symptoms should last at least four consecutive days, most of the days, and almost every day (Angst et al., 2019). In both disorders, the symptoms should not be attributed to other causes such as substance abuse, medication use, or other mental health problems.

Special Populations and Special Considerations

Children, adolescents, pregnant and post-partum mothers, and older adults are special populations that must be treated with care when diagnosed with bipolar I disorder. Diagnosis of bipolar I disorder in children and adolescents is difficult because of the existence of comorbidities. Often, they present to the hospital with mixed or atypical features of bipolar spectrum disorders such as irritability, rapid cycling of symptoms, and labile mood. They might also have other coexisting problems such as substance abuse, which makes it challenging to diagnose bipolar affective spectrum disorders. Adolescents might also present with symptoms such as paranoia, bizarre behaviors, and incongruent mood, which makes diagnosis difficult. Therefore, practitioners should emphasize the context of symptom occurrence during screening and use the DSM-5 diagnostic tool to develop accurate diagnoses (Gautam et al., 2019). In addition, tools such as the Kiddie Schedule for Affective Disorders and Schizophrenia should be used to overcome difficulties in diagnosis.

The typical onset of bipolar spectrum disorders is in the early twenties. This means that its occurrence overlaps with pregnancy and childbirth periods. The risk of bipolar I disorder relapse among pregnant and post-partum women is high because of hormonal factors, medication discontinuation, and distressing experiences such as sleep deprivation during these periods. Treatment of bipolar spectrum disorders during pregnancy and the post-partum period is also associated with considerable ethical and clinical issues (Singh & Deep, 2022). Healthcare providers must weigh the risks and benefits of bipolar treatments to the unborn fetus and relapse of bipolar I disorder.

A diagnosis of bipolar I disorder among older adults is challenging for most practitioners. This is because of the underestimated incidence of bipolar I disorder in this population and the limited applicability of DSM5 and ICD10 to this population. Practitioners might also misjudge older adults for other conditions since physical illnesses produce symptoms seen in most mental health problems. There is also an increased risk of harm from pharmacological treatments due to polypharmacy among the elderly population (Ljubic et al., 2021). Physiological changes with aging such as decreased drug absorption, metabolism, and elimination also affect bipolar I disorder treatment in older adults. For instance, older adults have diminished drug-binding ability to plasma due to low albumin, which increases the risk of adverse drug reactions among them. Therefore, practitioners must weigh the benefits and risks of the different treatments to ensure safety and quality outcomes in the treatment process.

Some of the ethical considerations that inform nurse practitioners’ decisions in treating bipolar I disorder in the above vulnerable populations include the promotion of patient autonomy, beneficence, non-maleficence, and data integrity. For example, weighing the risks of pharmacological treatments for bipolar I disorder on the developing fetus in pregnant women aims at ensuring safety, hence, non-maleficence. Practitioners must also provide care within their areas of specialization and by state laws to avoid legal issues such as malpractice in the care of patients with bipolar I disorder. Cultural practices affect the uptake and utilization of different treatments for bipolar I disorder. For example, practices during pregnancy rooted in culture might result in poor treatment adherence among mothers with bipolar I disorder (Singh & Deep, 2022). Practitioners should strive to address social determinants of health such as costs, access, and availability of mental health services to improve health outcomes for vulnerable populations.

FDA and/or Clinical Practice Guidelines

A range of drug options is available for treating bipolar I disorder. They include mood stabilizers, antidepressants, antipsychotics, and somatic treatments. Mood stabilizers include lithium, divalproex, lamotrigine, topiramate, and gabapentin. Antidepressants include tricyclic antidepressants, serotonin and norepinephrine reuptake inhibitors, selective serotonin reuptake inhibitors, mirtazapine, and bupropion. Antipsychotics include first and second generation antipsychotics (Rhee et al., 2020). Clinical practice guidelines recommend the use of monotherapy or a combination of lithium, lamotrigine, quetiapine, olanzapine-fluoxetine combination, valproate+lithium, valpropate+antidepressant in the acute stage. It also recommends combination therapy comprising a mood stabilizer/antipsychotics+antidepressants for acute bipolar I disorder. Maintenance therapy is achievable with olanzapine, risperidone, and valproate or lithium, lamotrigine, and antipsychotics with a focus on dose optimization (Fountoulakis et al., 2020). The FDA has approved olanzapine plus fluoxetine combination, quetiapine, cariprazine, lurasidone, and lumateperone for treating bipolar spectrum disorders.

Side Effects, FDA Warnings, and Monitoring

Patients prescribed the above treatments should be monitored for side and adverse effects. Antidepressants are associated with side effects that include insomnia, decreased libido, and weight gain. Patients should be monitored for adverse effects such as suicidal thoughts and serotonin syndrome. Antipsychotics are associated with side effects such as dizziness, dry mouth, dyskinesia, and sedation. Patients should be monitored for adverse reactions such as heart rhythm changes through scheduled electrocardiography tests. Patients who have been prescribed lithium should be monitored for nausea, diarrhea, excessive urination, and vomiting since they predispose patients to lithium toxicity (Hedya et al., 2023).

Examples of Proper Prescription

Name:

Age: 55 years

Diagnosis: Bipolar I disorder

Treatment

Oral fluoxetine 20 mg once daily 1/12

Refills: None

Date:

Name and signature

Name:

Age: 25 years

Diagnosis: Bipolar I disorder

Treatment

Oral lithium 600 mg twice daily 2/52

Refills: None

Date:

Name and signature

Name:

Age: 34 years

Diagnosis: Bipolar I disorder

Treatment

Oral lamotrigine 200 mg once daily 1/52

Refills: None

Date:

Name and signature

Conclusion

In summary, this paper has examined the prevalence and neurobiology of bipolar I disorder. It is evident from the analysis that bipolar I disorder differs from bipolar II disorder. Practitioners should be aware of the special considerations for vulnerable populations. Different medications can be used in acute and maintenance treatment for bipolar I disorder. Patients should be monitored for side and adverse effects of the different treatments.

 

 

References

Angst, J., Rössler, W., Ajdacic-Gross, V., Angst, F., Wittchen, H. U., Lieb, R., Beesdo-Baum, K., Asselmann, E., Merikangas, K. R., Cui, L., Andrade, L. H., Viana, M. C., Lamers, F., Penninx, B. W., de Azevedo Cardoso, T., Jansen, K., Dias de Mattos Souza, L., Azevedo da Silva, R., Kapczinski, F., … Vandeleur, C. L. (2019). Differences between unipolar mania and bipolar-I disorder: Evidence from nine epidemiological studies. Bipolar Disorders, 21(5), 437–448. https://doi.org/10.1111/bdi.12732

Fountoulakis, K. N., Yatham, L. N., Grunze, H., Vieta, E., Young, A. H., Blier, P., Tohen, M., Kasper, S., & Moeller, H. J. (2020). The CINP Guidelines on the Definition and Evidence-Based Interventions for Treatment-Resistant Bipolar Disorder. International Journal of Neuropsychopharmacology, 23(4), 230–256. https://doi.org/10.1093/ijnp/pyz064

Gautam, S., Jain, A., Gautam, M., Gautam, A., & Jagawat, T. (2019). Clinical Practice Guidelines for Bipolar Affective Disorder (BPAD) in Children and Adolescents. Indian Journal of Psychiatry, 61(Suppl 2), 294–305. https://doi.org/10.4103/psychiatry.IndianJPsychiatry_570_18

Hedya, S. A., Avula, A., & Swoboda, H. D. (2023). Lithium Toxicity. In StatPearls. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK499992/

Ljubic, N., Ueberberg, B., Grunze, H., & Assion, H.-J. (2021). Treatment of bipolar disorders in older adults: A review. Annals of General Psychiatry, 20, 45. https://doi.org/10.1186/s12991-021-00367-x

McIntyre, R. S., Berk, M., Brietzke, E., Goldstein, B. I., López-Jaramillo, C., Kessing, L. V., Malhi, G. S., Nierenberg, A. A., Rosenblat, J. D., Majeed, A., Vieta, E., Vinberg, M., Young, A. H., & Mansur, R. B. (2020). Bipolar disorders. The Lancet, 396(10265), 1841–1856. https://doi.org/10.1016/S0140-6736(20)31544-0

Rhee, T. G., Olfson, M., Nierenberg, A. A., & Wilkinson, S. T. (2020). 20-Year Trends in the Pharmacologic Treatment of Bipolar Disorder by Psychiatrists in Outpatient Care Settings. American Journal of Psychiatry, 177(8), 706–715. https://doi.org/10.1176/appi.ajp.2020.19091000

Scaini, G., Valvassori, S. S., Diaz, A. P., Lima, C. N., Benevenuto, D., Fries, G. R., & Quevedo, J. (2020). Neurobiology of bipolar disorders: A review of genetic components, signaling pathways, biochemical changes, and neuroimaging findings. Brazilian Journal of Psychiatry, 42(5), 536–551. https://doi.org/10.1590/1516-4446-2019-0732

Singh, S., & Deep, R. (2022). Pharmacological treatment of bipolar disorder in pregnancy: An update on safety considerations. Indian Journal of Pharmacology, 54(6), 443–451. https://doi.org/10.4103/ijp.ijp_407_21

Young, A. H., & Juruena, M. F. (2021). The Neurobiology of Bipolar Disorder. In A. H. Young & M. F. Juruena (Eds.), Bipolar Disorder: From Neuroscience to Treatment (pp. 1–20). Springer International Publishing. https://doi.org/10.1007/7854_2020_179

 

Individuals suffering from bipolar disorder face unexpected and sometimes perplexing symptoms daily. The disorder’s cause is still a mystery despite ongoing research. An imbalance in brain chemistry that affects mood regulation, specific brain characteristics, very stressful experiences, a history of abuse or trauma, and a family history of the disease or other mental disorders are some of the factors associated with bipolar disorder (Baldessarini et al., 2018). There are four basic types of bipolar disorder, each with specific features. The purpose of this paper is to assess the prevalence and neurobiology of bipolar I disorder, differentiate between bipolar I and bipolar II disorders, address specific groups, discuss FDA-approved treatment, and study medicines for the treatment of bipolar I disorder.

Prevalence and Neurobiology

A psychiatric disease known as bipolar disorder, often called manic-depressive disorder, is characterized by rapid changes between depressive and manic episodes. According to the National Institute on Mental Illness, bipolar illness often manifests in adolescence or the early stages of adulthood and affects 5.7 million persons in the United States (2.6% of the adult population) (Carvalho et al., 2020). The bulk of BD heritability is due to common, inconsequential polymorphisms. Many risk genes and genetic networks have been uncovered. Calcium signaling is important among inherited risk pathways and appears to have the most potential as a therapy. Digital technologies, as well as complicated mathematical and statistical studies, are being used to assess and interpret BD. These innovative methods of BD support and reflect a reframing of the disorder as one characterized by continuous instability in mood and neural circuitry.

 

Differences in Bipolar I and Bipolar II Disorder

The most prevalent bipolar types are 1 and 2. They also have a lot in common, particularly given that both can result in spells of hypomania and despair. There is, however, one significant distinction: mania is not a feature of bipolar disorder type 2; it is only a feature of bipolar disorder type 1 (Kato, 2019). This is significant since manic episodes can significantly impair your life and perhaps need hospitalization.

The DSM-5 and the ICD-11 kept the difference between BD-1 and BD-2. Both systems believe that BD-2 consists of recurrent major depressive episodes with mood and activity increases that are seldom more severe than hypomania and infrequently entail psychosis, especially during [hypo]manic stages (McIntyre et al., 2020). The DSM-5 does not, however, recognize the criteria for BD-2 that were provided for BD-1, including the polarity associated with the most recent events, the severity of events, the presence of mixed/psychotic features, or the extent of remission. Furthermore, it has been demonstrated that mood-stabilizing treatments can be effective in both BD-1 and BD-2. Although antidepressants commonly prove to be less effective and potentially destabilizing, antipsychotics and certain other antimanic treatments are generally not necessary for hypomania in BD-2.

Special Population and Considerations

Age and other physical characteristics may have an impact on how depression and bipolar illnesses manifest and are treated. The severity of mood symptoms in young children is less clear-cut than in adults, thus pharmaceutical treatment should be provided at modest dosages with thorough monitoring for adverse effects (Rhee et al., 2020). The diagnosis of depression in the perinatal population depends more on emotional than on physical symptoms because the latter may be a side effect of the gravid condition. In this demographic, treating mood disorders requires striking a fine balance between promptly alleviating negative symptoms and guarding against adverse drug reactions in children. For senior patients who mostly appear with chronic diseases or recent loss, it’s crucial to be sensitive to the possibility of depression. Due to age-retarded drug metabolism, mood problems may mimic physical complaints, and drugs should be taken carefully.

Clinicians may face particular legal and ethical issues while treating people with bipolar illnesses. For instance, due to their impulsivity, lack of understanding, and poor judgment, individuals with manic and mixed-mood states may be unable to offer informed consent or make wise decisions on their treatment (McIntyre et al., 2020). Moreover, some clinical manifestations, such as impatience, grandiosity, and delusional thinking, might endanger the therapeutic relationship. Moreover, due to the relapsing-remitting nature of the illness, patients may occasionally feel better and doubt the necessity of continuing therapy, thus putting the clinician’s treatment objectives at odds with the patient’s autonomy in decision-making.

According to statistics, those who have mental diseases experience worse social determinants of health. Some patients might not have jobs, have inadequate jobs, or have insecure jobs (Carvalho et al., 2020). The absence of employment usually results in a lack of money and, consequently, a lack of means to support oneself. Those with lesser incomes than those with higher wages have also been found to have poorer mental health. This might signal that the patient lacks access to running water, electricity, or money to buy food. Worse effects on mental health follow from this.

Pharmacological Treatment

Mood stabilizers and antipsychotics are a few of the drugs the FDA has approved for use in the treatment of the bipolar disorder (Baldessarini et al., 2018). One medicine should be begun at a time, with additional ones added as necessary, just like with any novel pharmacologic therapy. Use the smallest quantity possible if the patient reacts to one medication (Yalin & Young, 2020). It is also simple to determine which medications work the best or have the worst side effects. Risperidone 3 mg orally daily, Lamotrigine 200 mg orally daily, or Lithium 0.8 mg daily would be given as monotherapy, depending on the patient’s presentation (Rhee et al., 2020). Manic and mixed episodes are treated with risperidone. Lamotrigine or lithium is suggested for maintenance. The patient may also think about starting psychotherapy, particularly family-centered counseling.

The medicine used to treat bipolar illness, among other medications, can have dangerous side effects (Yalin & Young, 2020). Sleepiness, increased appetite, fatigue, coughing, urine incontinence, excessive saliva, diarrhea, ataxia, nausea, dizziness, tremor, acne, and dyspepsia are among the most prevalent side effects of risperidone (Baldessarini et al., 2018). Those with diabetes should take risperidone cautiously as it may result in hyperglycemia. Regular blood glucose checks are necessary. A month after the initial dosage and then every six months thereafter, CBC testing should be performed since risperidone has the potential to induce leukopenia, neutropenia, and agranulocytosis. Risperidone use may result in seizures, orthopnea, and a higher incidence of suicidal thoughts.

Lithium may cause tremors, seizures, lightheadedness, somnolence, agitation, arrhythmias, tachycardia, nausea, and many other serious adverse effects (Carvalho et al., 2020). Lithium toxicity can occur, thus it’s important to monitor levels often. Even extremely close to therapeutic levels, toxicity can still develop. Lithium use should be avoided by patients who are pregnant since it might affect the unborn child. Insufficient renal and cardiac performance is also a warning against using lithium (McIntyre et al., 2020). For patients, these labs ought to be additionally examined. A CBC and kidney function test should be examined after one month of therapy and then every 6 months after that

Proper Prescriptions

Conclusion

Although many individuals have a preponderance of one or the other, bipolar illnesses are characterized by bouts of mania and depression that may alternate. Sociocultural factors, alterations in brain neurotransmitter levels, and heredity may all be involved, even though the exact cause is unknown. A diagnosis is made by looking at the past. Treatment consists of psychotherapy and mood-stabilizing drugs. 

References

Baldessarini, R. J., Tondo, L., & Vázquez, G. H. (2018). Pharmacological treatment of adult bipolar disorder. Molecular Psychiatry, 24(2), 198–217. https://doi.org/10.1038/s41380-018-0044-2

Carvalho, A. F., Firth, J., & Vieta, E. (2020). Bipolar Disorder. New England Journal of Medicine, 383(1), 58–66. https://doi.org/10.1056/nejmra1906193

Kato, T. (2019). Current understanding of bipolar disorder: Toward integration of biological basis and treatment strategies. Psychiatry and Clinical Neurosciences, 73(9), 526–540. https://doi.org/10.1111/pcn.12852

McIntyre, R. S., Berk, M., Brietzke, E., Goldstein, B. I., López-Jaramillo, C., Kessing, L. V., Malhi, G. S., Nierenberg, A. A., Rosenblat, J. D., Majeed, A., Vieta, E., Vinberg, M., Young, A. H., & Mansur, R. B. (2020). Bipolar disorders. The Lancet, 396(10265), 1841–1856. https://doi.org/10.1016/s0140-6736(20)31544-0

Rhee, T. G., Olfson, M., Nierenberg, A. A., & Wilkinson, S. T. (2020). 20-Year Trends in the Pharmacologic Treatment of Bipolar Disorder by Psychiatrists in Outpatient Care Settings. American Journal of Psychiatry, appi.ajp.2020.1. https://doi.org/10.1176/appi.ajp.2020.19091000

Yalin, N., & Young, A. H. (2020). Pharmacological Treatment of Bipolar Depression: What are the Current and Emerging Options? Neuropsychiatric Disease and Treatment, Volume 16, 1459–1472. https://doi.org/10.2147/ndt.s245166

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