Assessing and Treating Patients with Bipolar Disorder

Assessing and Treating Patients with Bipolar Disorder

Mental health disorders are rising in the US, with over 21% of US citizens reporting a mental illness (NIMH, 2022). In addition, they cause significant problems that include lost productivity, disturbed family processes, high healthcare costs, and self-harm. Knowledge of clinical presentations, the disease’s pathophysiology, and neurobiology help healthcare providers make the right treatment decisions. A nurse must also differentiate the disorder from others to ensure the right therapy is delivered, reduce delays in treatment access, and increase remission.

Bipolar and bipolar-related disorders are mental disorders characterized by changes in mood and oscillations between depression and an elevated mood. The differences in the specific disorders depend on the severity or presence of both extremes. This paper evaluates a bipolar disorder, its neurobiology, prevalence, compares it to another disorder, and discusses the treatment modalities.

Neurobiology and Prevalence of Bipolar I Disorder

Bipolar I disorder presents with special presentations such as mania and severe circadian dysfunction, which could have neurobiological sources. Young and Jururena (2021) note that bipolar I disorder is a complex multidimensional neuropsychiatric disorder presenting with depression and mania episodes. The neurobiology of the disorder is complex, and neuroimaging, genetics, and epigenetics studies have helped improve knowledge of the condition and subsequent management.

An analysis of participants shows that the patients with the disorder are associated with a significant cortical gray matter volume. The specific areas affected by the condition are the left anterior cingulate and right fronto-insular cortex (Young & Juruena, 2021).

MRI images have shown increased white matter hyperintensities in weighted T2 images (Young & Juruena, 2021). Studies also show that individuals with bipolar I disorder have decreased white matter integrity. Analysis of postmortem morphometrics shows changes in emotional regulation centers such as decreased neuronal sizes, glial, and neuronal density. The genetic heritability of the disorder is high (between 80% and 90%), but the genetic component remains unknown (NIMH, 2022).

Limited studies evaluate Bipolar 1 Disorder neural changes with other disorders like unipolar depression. Recent studies show that bipolar disorder patients show a significantly smaller hippocampus and amygdala than those with unipolar depression. Alternatively, individuals with unipolar depression show significantly decreased anterior cingulate gyrus. More studies are required to study the genetic and structural changes in bipolar disorder. These neurobiological changes in bipolar disorder are promising as future diagnostic tools.

The disorder results from genetic factors and exposure, precipitating and predisposing environmental factors such as stress and trauma. Thus, there is a huge link between the disorder and other mood disorders. Young and Juruena (2021) Dysfunctions in intracellular processes, oxidative stress, and mitochondrial disorders lead to neuron membrane damage, subsequent loss of brain tissue death, and decreased brain volumes, as seen above.

Peripheral biomarkers of hormones, inflammation, oxidative stress, and neurotrophins are often elevated in bipolar disorder in acute episodes. Recurrent episodes lead to system toxicity and damage to the neuronal system, hence the progressive development of the disease, neuroplasticity, and problems with treatment.

The national institute of mental health (NIMH) collects and reports data on mental health issues. NIMH shows that having a first-degree relative exposes individuals to a 5-10% risk for the disorder, and 80-90% of individuals with bipolar disorder have a relative with the disease. The prevalence of bipolar I disorder in the US is estimated to be between 0.5-1.0% (NIMH, 2022). Bipolar disorder affects about 2.8% of the population. There is a 4.4.% risk of contracting the disease in the lifetime of adults 18+ years.

Bipolar 1 Disorder VS Bipolar II Disorder

Bipolar II is the disorder of interest for comparison with Bipolar Disorder I. These two conditions present with similar presentations of depression and mania, but the severity significantly differs. In bipolar 1 disorder, the individual fluctuates between mania and major depressive episodes or experiences a mix of these episodes (Ha et al., 2019). The patient must have experienced at least one manic episode that lasts 1 week or leads to hospitalization (Ha et al., 2019). The hospitalization and duration help confirm actual mania. However, a depressive episode is not required for a diagnosis of bipolar I.

During manic episodes, individuals participate in risky activities such as driving at high speeds, and can lead to self-harm or harm to others. In addition, the patient must also present with three of the following symptoms increased self-esteem or delusions of grandeur, decreased sleep and need for it, flight of ideas, easily distracted, agitation (psychomotor), and increased goal-directed activity such as work, school, social, and sexual activities. These patients exhibit risky behaviors such as violence, jumping from high heights, and driving at high speeds.

Bipolar II disorder is diagnosed when an individual has at least one current or past hypomania episode and one current or past major depression lasting more than two weeks (Ha et al., 2019). However, the patient must not have a history of manic episodes.

Hypomanic episodes are less severe compared to mania. Symptoms of bipolar II disorder also include increased talkativeness than usual, decreased need for sleep, having an elated mood (feeling like on top of the world), easy distractibility, increased sex drive, and engaging in risky behaviors such as sprees and impulsive decisions (Ha et al., 2019). Depressive symptoms include lost interest in activities, hopelessness, and worthlessness feelings. The disorder’s symptoms are not severe enough to cause psychosis or affect routine activities.

Special Populations

Children and adolescents are affected by the disorder resulting from a genetic predisposition. Bipolar disorder in children and adults causes various issues, such as unruly behavior, suicidal thoughts, and running away from home. Most cultures see children and adults with bipolar I disorder as problematic and subject them to harsh discipline. Cultural and spiritual beliefs can hinder access to treatment services in this population, primarily because their care decisions depend on their children (Findling et al., 2020).

Bipolar disorder accounts for about 6-10% of senior clinic visits. Older adults are often hospitalized due to manic episodes with presentations such as violence. The disease in older adults has a low association with a family predisposition, and most episodes result from social determinants of health such as occupation. The disorder is associated with many issues, such as an increased risk for fatality and decreased response to treatment.

Bipolar disorders can worsen pregnancy, and pregnant women with bipolar disorders have a higher admission rate than pregnant women without bipolar disorders. Bipolar 1 disorder patients are monitored throughout pregnancy, especially in the third trimester, because of the high risk for symptoms worsening.

For postpartum mothers, bipolar disorder can significantly worsen, and the child’s safety is always a priority. Prolonging the mother’s stay at the hospital can help monitor and stabilize their mood to prevent them from harming themselves or the babies. Javed (2019) notes that factors affecting the prevalence of the disorder/ determinants of health in pregnant women include employment status, family stability, and other stresses.

Bipolar disorder symptoms, such as engaging in risky behaviors and agitation, increase visits to the emergency department. Bipolar one disorder patients experience hypomania episodes. More than 2 million bipolar disorder patients sought healthcare services in the emergency department (Eseaton et al., 2022).

Other disorders causing emergency department visits include anxiety disorders, poisoning, and suicidal ideas are the leading causes of ED visits (Eseaton et al., 2022). Eseaton et al. (2022) also note that most individuals who are brought to the ED with Bipolar disorder are from low-income families

Treatment of Bipolar I Disorder

The best treatment interventions for bipolar disorders are mood stabilizers and medications to help manage manic and major depressive episodes (Stern et al., 2019). Some of the FDA-approved drugs for acute mania are chlorpromazine, olanzapine, risperidone, quetiapine, ziprasidone, and aripiprazole (Kishi et al., 2022).

Aripiprazole is the drug of choice for acute mania. Seroquel/ quetiapine is the only FDA-approved drug for acute and adjunctive therapy for acute major depression. Aripiprazole and Quetiapine are FDA-approved drugs for mixed episodes as monotherapy (Verdolini et al., 2018). The choice medication is Seroquel. Seroquel is an antidepressant and a good maintenance therapy for depression.

Cariprazine is also a good maintenance therapy to help manage mixed episodes, and aripiprazole is the drug of choice in maintenance therapy for bipolar mania (Earley et al., 2019). Thus, the drugs of choice are Seroquel, cariprazine, and aripiprazole. However, patients present with various symptoms, and drugs are provided according to presenting symptoms and adjusted over time.

The most common side effects of sertraline are decreased libido, desire, drive, erection, performance, and ejaculation. There are Cariprazine side effects, including allergic reactions leading to hives and swelling in the face, lip, and tongue. Aripiprazole causes akathisia, fatigue, drowsiness, headaches, nausea, dizziness, and weight gain.

Lab measures that are necessary include blood pressure, urea and electrolytes, weight, lipid panel, and closely monitoring serum sodium. Antipsychotic medications are associated with increased risk for weight gain and hypernatremia hence the need to check them regularly (Gettu & Saadabaddi, 2022).

Antpsychotics also impose various changes in the electrolytes such as sodium and potassium hence the regular measurement. Weight changes help the professionals make decisions on various issues such as therapy changes for better outcomes while maintaining the body’s physiology.

Medications Prescription examples

  1. Medication for bipolar I disorder

Rx.

Aripiprazole                      2mg

Make 14 such doses

Label: take one tablet once daily

  1. Medication for bipolar depressive episodes

Rx

Seroquel                           50mg

Make 14 such doses

Label: take one tablet once daily

  1. Medication for Mixed episodes

Rx

Cariprazine                      1.5mg

Make 14 such dose

Conclusion

Mental health disorders vary greatly depending on the disease’s specific neurobiology and pathophysiology. Bipolar and bipolar-related disorders are mood disorders marked by depression and mania changes. Bipolar one disorder is characterized by mania and major depression, though major depression is not a prerequisite for diagnosing bipolar I disorder. The condition is differentiated from bipolar II in that bipolar II elated mood/mania is less severe (hypomania), and at least a significant depression episode lasting two weeks is required for the diagnosis.

Management entails FDA-approved drugs to manage bipolar mania, major depression, and mixed episodes. Medications for acute episodes also differ from medications from maintenance therapy. The choice of medications differs with patient response to medications hence the need for frequent clinic visits, especially at the beginning of the treatment. Treatment changes can be done using drugs in the same class or FDA-approved medications.

References

Earley, W., Burgess, M. V., Rekeda, L., Dickinson, R., Szatmári, B., Németh, G., McIntyre, R. S., Sachs, G. S., & Yatham, L. N. (2019). Cariprazine treatment of bipolar depression: a randomized, double-blind placebo-controlled phase 3 study. American Journal of Psychiatry176(6), 439-448. https://doi.org/10.1176/appi.ajp.2018.18070824

Eseaton, P. O., Oladunjoye, A. F., Anugwom, G., Onyeaka, H., Edigin, E., & Osiezagha, K. (2022). Emergency department utilization by patients with bipolar disorder: a national population-based study. Journal of Affective Disorders313, 232-234. https://doi.org/10.1016/j.jad.2022.06.086

Findling, R. L., Stepanova, E., Youngstrom, E. A., & Young, A. S. (2018). Progress in diagnosis and treatment of bipolar disorder among children and adolescents: an international perspective. Evidence-Based Mental Health21(4), 177-181. http://dx.doi.org/10.1136/eb-2018-102912

Gettu, N., & Saadabadi, A. (2021). Aripiprazole. In StatPearls [Internet]. StatPearls Publishing.

Ha, K., Ha, T. H., & Hong, K. S. (2019). Bipolar I and bipolar II: it’s time for something new for a better understanding and classification of bipolar disorders. The Canadian Journal of Psychiatry64(8), 548-549. http://dx.doi.org/10.1177/0706743719861279

Kishi, T., Ikuta, T., Matsuda, Y., Sakuma, K., Okuya, M., Nomura, I., … & Iwata, N. (2022). Pharmacological treatment for bipolar mania: a systematic review and network meta-analysis of double-blind, randomized controlled trials. Molecular Psychiatry, 27(2), 1136-1144. https://doi.org/10.1038/s41380-021-01334-4

National Institute of Mental Health (NIMH), (2022). Mental Health Information. https://www.nimh.nih.gov/

Stern, T. A., Favo, M., Wilens, T. E., & Rosenbaum, J. F. (2016). Massachusetts General Hospital psychopharmacology and neurotherapeutics. Elsevier.

Assessing and Treating Patients with Bipolar Disorder Instructions

  Examine Case Study: An Asian American Woman. Diagnosis-Bipolar Disorder. You will be asked to make three decisions concerning the medication to prescribe to this patient. Be sure to consider factors that might impact the patient’s pharmacokinetic and pharmacodynamic processes.

At each decision point, you should evaluate all options before selecting your decision and moving throughout the exercise. Before you make your decision, make sure that you have researched each option and that you evaluate the decision that you will select. Be sure to research each option using the primary literature.

Introduction to the case (1 page)

Briefly explain and summarize the case for this Assignment. Be sure to include the specific patient factors that may impact your decision making when prescribing medication for this patient.
Decision #1 (1 page)

Which decision did you select?
Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.
Decision #2 (1 page)

Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.
Decision #3 (1 page)

Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.
Conclusion (1 page)

Summarize your recommendations on the treatment options you selected for this patient. Be sure to justify your recommendations and support your response with clinically relevant and patient-specific resources, including the primary literature.

Verdolini, N., Hidalgo‐Mazzei, D., Murru, A., Pacchiarotti, I., Samalin, L., Young, A. H., … & Carvalho, A. F. (2018). Mixed states in bipolar and major depressive disorders: a systematic review and quality appraisal of guidelines. Acta Psychiatrica Scandinavica138(3), 196-222. https://doi.org/10.1111/acps.12896

Young, A. H., & Juruena, M. F. (2020). The neurobiology of bipolar disorder. In Bipolar Disorder: From Neuroscience to Treatment (pp. 1-20). Springer, Cham. http://dx.doi.org/10.1007/7854_2020_179