chapter 14 bipolar disorders

therapeutic lithium

0.8-1.4 watch salt intake Blood levels need to be checked frequently at first and then after 6 months to a year can go to every 3 months. The blood should be drawn in the AM 8-12 hours after the last dose.

other treatments

*Electroconvulsive therapy (ECT)* is used to subdue severe manic behavior, especially in patients with treatment-resistant mania and patients with rapid cycling (i.e., those who experience four or more episodes of illness a year). Depressive episodes—particularly those with severe, catatonic, or treatment-resistant depression—are an indication for this treatment and may be helpful for mania during pregnancy ECT is effective for patients with bipolar disorder who have rapid cycling, for those with paranoid-destructive features (who often respond poorly to lithium therapy), and in acutely suicidal patients. *Milieu management* *Support groups* *Health teaching and health promotion* Patients and families need information about bipolar illness, with particular emphasis on its chronic and highly recurrent nature. In addition, patients and families need to be taught the warning signs and symptoms of impending episodes. For example, *changes in sleep patterns are especially important because they usually precede, accompany, or precipitate mania*. *Even a single night of unexplainable sleep loss can be taken as an early warning of impending mania*. Health teaching stresses the importance of establishing regularity in sleep patterns, meals, exercise, and other activities.

Thought Processes and Speech Patterns

*Flight of ideas* is a nearly continuous flow of accelerated speech with abrupt changes from topic to topic that are usually based on understandable associations or plays on words. At times, the attentive listener can keep up with the flow of words, even though direction changes from moment to moment. Speech is rapid, verbose, and circumstantial (including minute and unnecessary details). When the condition is severe, speech may be disorganized and incoherent. The incessant talking often includes joking, puns, and teasing The content of speech is often sexually explicit and ranges from grossly inappropriate to vulgar. Themes in the communication of the individual with mania may revolve around extraordinary sexual prowess, brilliant business ability, or unparalleled artistic talents (e.g., writing, painting, and dancing). The person may actually have only average ability in these areas. Speech is not only profuse but also loud, bellowing, or even screaming. One can hear the force and energy behind the rapid words. As mania escalates, flight of ideas may give way to clang associations. Clang associations are the stringing together of words because of their rhyming sounds, without regard to their meaning *Grandiosity* (inflated self-regard) is apparent in both the ideas expressed and the person's behavior. People with mania may exaggerate their achievements or importance, state that they know famous people, or believe they have great powers. The boast of exceptional powers and status can take delusional proportions during mania. Grandiose persecutory delusions are common. For example, people may think that God is speaking to them or that the FBI is out to stop them from saving the world. Sensory perceptions may become altered as the mania escalates, and hallucinations may occur. However, no evidence of delusions or hallucinations is present during hypomania.

Biological factors (etiology)

*Genetic* have a strong heritability (i.e., the influence of genetic factors is much greater than the influence of external factors). Bipolar disorders are 80% to greater than 90% heritable, whereas Parkinson's disease, for example, is only 13% to 30% heritable. The rate of bipolar disorders may be as much as 5 to 10 times higher for people who have a relative with bipolar disorder than the rates found in the general population. It is likely that bipolar disorder is a polygenic disease, which means that a number of genes contribute to its expression. In a landmark study at the National Institute of Mental Health (NIMH), researchers found a connection between bipolar disorder and a genome that encodes an enzyme called diacylglycerol kinase eta (DGKH). Lithium is the first-line therapy for bipolar disorder, and DGKH is a crucial part of a lithium-sensitive pathway. Other research has focused on abnormal circadian genes that may result in a superfast biological clock, which manifests itself in extreme insomnia. The scientific community has been increasingly drawn to the concept of bipolar disorders and schizophrenia having similar genetic origins and pathology. Both disorders exhibit irregularities on chromosomes 13 and 15. It may be that the genotype has more to do with the specific expression of psychoses (altered thought, delusions, and hallucinations) than are reflected in traditional classification systems. Current psychiatric diagnostic systems will undoubtedly be modified as advances are made in molecular genetics, which will revolutionize our understanding and treatment of many psychotic disorders. *Neurobiological* *not enough or receptor site insensitivity, norepinperine, dopamine, serotonin, structural and functional changes* Neurotransmitters (norepinephrine, dopamine, and serotonin) have been studied since the 1960s as causal factors in mania and depression. One simple explanation is that too few of these chemical messengers will result in depression, and an oversupply will cause mania. However, proportions of neurotransmitters in relation to one another may be more important. Receptor site insensitivity could also be at the root of the problem—even if there is enough of a certain neurotransmitter, it is not going where it needs to go. Additional research has found that the interrelationships in the neurotransmitter system are complex, and more elaborate theories have been developed since the amine hypotheses were originally proposed. Mood disorders are most likely a result of interactions among various chemicals, including neurotransmitters and hormones. Brain pathways implicated in the pathophysiology of bipolar disorder are located in subregions of the prefrontal cortex (PFC) and medial temporal lobe (MTL). Dysregulation in the neurocircuits surrounding these areas have been viewed through functional imaging (e.g., positron emission tomography [PET] scans, magnetic resonance imaging [MRI]). Neuroimaging studies reveal structural and functional brain changes in people with bipolar disorder. Some structural changes seem to cause the disorder, and some seem to be caused by the disorder. For example, prefrontal cortical changes are evident in the early stages of the illness, whereas lateral ventricle abnormalities develop with repeated episodes of mania and/or depression. Functional imaging also reveals differences in the anterior limbic regions of the brain, which are associated with emotion, motivation, memory, and fear—the areas most deeply affected by bipolar disorder. *Neuroendocrine* The hypothalamic-pituitary-thyroid-adrenal (HPTA) axis has been closely scrutinized in people with mood disorders. *Hypothyroidism is known to be associated with depressed moods, and hypothyroidism is seen in some patients experiencing rapid cycling* High-dose thyroid hormone administration has been suggested as a method to improve outcomes in treatment-resistant bipolar disorder

Lithium carbonate

*Indications* •Therapeutic and toxic levels -Therapeutic blood level 0.8 to 1.4 mEq/L -Maintenance blood level 0.4 to 1.3 mEq/L -Toxic blood level: 1.5 to 2.0 mEq/L •Maintenance therapy need to be given lithium for 9 to 12 months, and some patients may need lifelong lithium maintenance to prevent further relapses. Many patients respond well to lower dosages during maintenance or prophylactic lithium therapy. is unquestionably effective in preventing both manic and depressive episodes in patients with bipolar disorder. Therefore, the patient and family should be given careful instructions about (1) the purpose and requirements of lithium therapy, (2) its adverse effects, (3) its toxic effects and complications, and (4) situations in which the physician should be contacted. *The patient and family should also be advised that suddenly stopping lithium can lead to relapse and recurrence of mania*. Health care providers must stress to patients and their families the importance of discontinuing maintenance therapy gradually. *Patients need to know that two major long-term risks of lithium therapy are hypothyroidism and impairment of the kidney's ability to concentrate urine*. Therefore, a person receiving lithium therapy must have periodic follow-ups to assess thyroid and renal function. •Contraindications Before lithium is administered, a medical evaluation is performed to assess the patient's ability to tolerate the drug. In particular, baseline physical and laboratory examinations should include assessment of renal function; determination of thyroid status, including levels of thyroxine and thyroid-stimulating hormone; and evaluation for dementia or neurological disorders, which presage a poor response to lithium. Other clinical and laboratory assessments, including an electrocardiogram, are performed as needed, depending on the individual's physical condition. is generally contraindicated in patients with cardiovascular disease, brain damage, renal disease, thyroid disease, or myasthenia gravis. Whenever possible, lithium is not given to women who are pregnant, because it may harm the fetus. The fear of becoming pregnant and the wish to become pregnant are both major concerns for many women taking lithium. Lithium use is also contraindicated in mothers who are breast-feeding and in children younger than 12 years of age.

continuation phase

*lasts for 4 to 9 months. Although the overall outcome of this phase is relapse prevention*, many other outcomes must be accomplished to achieve relapse prevention. These outcomes include: •Psychoeducational classes for patient and family related to: ○Knowledge of disease process ○Knowledge of medication ○Consequences of substance addictions for predicting future relapse ○Knowledge of early signs and symptoms of relapse •Support groups or therapy (cognitive-behavioral, interpersonal) •Communication and problem-solving skills training

assessment guidelines

1) assess danger to self and others exhaustation not eating or sleeping for days at a time poor impulse control uncontrolled spending 2) assess need to protection from uninhibited behaviors (giving away all of their money or possessions) 3) assess need for hospitalization to safeguard and stabilize the patient 4) assess medical status if mania is primary (mod bipolar disorder or cyclothmia) or secondary disorder 5) assess for coexisting medical conditions or situations that warrants special intervention (substance abuse anxiety disorder legal or financial cries) 6) assess patient and family's understanding of bipolar disorders, medications, and knowledge of support groups and origination that provide info on bipolar disorder

ADVANCED SIGNS OF TOXICITY (lithium)

1.5-2.0 mEq/L Coarse hand tremor, persistent gastrointestinal upset, mental confusion, muscle hyperirritability, electroencephalographic changes, incoordination, sedation Interventions outlined above or below should be used, depending on severity of circumstances.

severe toxicity (lithium)

2.0-2.5 mEq/L Ataxia, confusion, large output of dilute urine, serious electroencephalographic changes, blurred vision, clonic movements, seizures, stupor, severe hypotension, coma; death is usually secondary to pulmonary complications. Hospitalization is indicated. The drug is stopped, and excretion is hastened. If patient is alert, an emetic is administered.

EXPECTED SIDE EFFECTS (lithium)

<0.4-1.0 Fine hand tremor, polyuria, and mild thirst Mild nausea and general discomfort Weight gain Symptoms may persist throughout therapy. Symptoms often subside during treatment. Weight gain may be helped with diet, exercise, and nutritional management.

EARLY SIGNS OF TOXICITY (lithium)

<1.5 mEq/L Nausea, vomiting, diarrhea, thirst, polyuria, lethargy, slurred speech, muscle weakness, and fine hand tremor Medication should be withheld, blood lithium levels measured, and dosage reevaluated. Dehydration, if present, should be addressed.

SEVERE TOXICITY (lithium)

>2.5 mEq/L Convulsions, oliguria, and death can occur. In addition to the interventions above, hemodialysis may be used in severe cases.

Psychological factors (etiology)

Although there is increasing evidence for genetic and biological vulnerabilities in the etiology of the mood disorders, psychological factors may play a role in precipitating manic episodes for many individuals. In the absence of severe stressful events, it is possible that a person with a genetic predisposition and a neurochemical imbalance may never experience symptoms of bipolar disorder. However, once the disease has been triggered by an event that is perceived as stressful—loss of a relationship, financial difficulties, failing an exam, being accepted to a highly desirable graduate school—it no longer requires environmental stress to continue.

bipolar disorder

At least one episode of mania alternates with major depression. Psychosis may accompany the manic episode.

environmental factors (etiology)

Bipolar disorder is a worldwide problem that generally affects all races and ethnic groups equally, but some evidence suggests that bipolar disorders may be more prevalent in upper socioeconomic classes. The exact reason for this is unclear; however, people with bipolar disorders appear to achieve higher levels of education and higher occupational status than individuals with unipolar depression. The educational levels of individuals with unipolar depressive disorders, on the other hand, appear to be no different from those of individuals with no symptoms of depression within the same socioeconomic class. Also, the proportion of patients with bipolar disorders among creative writers, artists, highly educated men and women, and professional people is higher than in the general population.

evaluation

Evaluate outcome criteria Care plan reassessed Care plan revised if indicated

Bipolar II disorder

Hypomanic episode(s) alternate with major depression. Psychosis is not present. The hypomania of ___ disorder tends to be euphoric and often increases functioning and the depression tends to put people at particular risk for suicide.

Cyclothymia

Hypomanic episodes alternate with minor depressive episodes (at least 2 years in duration). Individuals tend to have irritable hypomanic episodes.

Epidemiology

Lifetime prevalence of bipolar disorder in the United States is 3.9% •Bipolar I - more common in males •Bipolar II - more common in females •Cyclothymia - usually begins in adolescence or early adulthood The lifetime prevalence, or the percentage of the population that has ever experienced bipolar disorder in the United States, has been estimated at 3.9%. The lifetime risk, or the percentage of the population that will have a bipolar disorder by age 75, is 5.1% . The median age of onset for bipolar I is 18 years; for bipolar II, the median age of onset is 20 years. Bipolar I tends to begin with a depressive episode—in women 75% of the time, in men 67% of the time. The episodes tend to increase in number and severity during the course of the illness. Bipolar I disorder seems to be somewhat more common among males, but bipolar II disorder (characterized by the milder form of mania—hypomania—and increased depression) is more common among females. Women with bipolar disorders are more likely to abuse alcohol, commit suicide, and develop thyroid disease; men with bipolar disorder are more likely to have legal problems and commit acts of violence. bipolar II disorder is underdiagnosed and often mistaken for major depression or personality disorders, when it actually may be the most common form of bipolar disorder. Clinicians may downplay bipolar II and consider it to simply be the milder version of bipolar disorders. However, it is a source of significant morbidity and mortality, particularly due to the occurrence of severe depression. one out of two people with depression may have bipolar II. Cyclothymia usually begins in adolescence or early adulthood. There is a 15% to 50% risk that an individual with cyclothymia will subsequently develop bipolar I or bipolar II disorder.

acute phase (planning)

Medical stabilization Maintaining safety Self-care needs planning focuses on medically stabilizing the patient while maintaining safety, and the hospital is usually the safest environment for accomplishing this. Nursing care is geared toward managing medications, decreasing physical activity, increasing food and fluid intake, ensuring at least 4 to 6 hours of sleep per night, alleviating any bowel or bladder problems, and intervening to see that self-care needs are met. Some patients may require seclusion or even electroconvulsive therapy

atypical Antipsychotics

Olanzapine (Zyprexa) Risperidone (Risperdal) In addition to showing sedative properties during the early phase of treatment (help with insomnia, anxiety, agitation), the atypical antipsychotics seem to have mood-stabilizing properties. Most evidence supports the use of olanzapine (Zyprexa) or risperidone (Risperdal). For example, an initial study showed that olanzapine is better tolerated and prevents mania relapse more effectively than lithium

advanced treatments

Psychotherapy Cognitive-behavioral therapy (CBT) Interpersonal and social rhythm therapy Pharmacotherapy and psychiatric management are essential in the treatment of acute manic attacks and during the continuation and maintenance phases of bipolar disorder. Individuals with bipolar disorder must deal with the psychosocial consequences of their past episodes and their vulnerability to experiencing future episodes. They also have to face the burden of long-term treatments that may involve unpleasant side effects. Many patients have strained interpersonal relationships, marriage and family problems, academic and occupational problems, and legal or other social difficulties. Psychotherapy can help them work through these difficulties, decrease some of the psychic distress, and increase self-esteem. Psychotherapeutic treatments can also help patients improve their functioning between episodes and attempt to decrease the frequency of future episodes. *Cognitive-behavioral therapy (CBT)* is typically used as an adjunct to pharmacotherapy and involves identifying maladaptive cognitions and behaviors that may be barriers to a person's recovery and ongoing mood stability. It is also used for bipolar disorder in children. CBT *focuses on adherence to the medication regimen, early detection and intervention for manic or depressive episodes, stress and lifestyle management, and the treatment of depression and comorbid conditions*. Patients treated with cognitive therapy are more likely to take their medications as prescribed than are patients who do not participate in therapy, and psychotherapy results in greater adherence to the lithium regimen A formalized psychotherapy called *interpersonal and social rhythm therapy* has been tested in combination with pharmacotherapy in randomized clinical trials as treatment for patients during the maintenance phase of bipolar illness. *This therapy addresses the variables that relate to recurrence of symptoms, especially nonadherence with medication, stress management, and maintenance of social supports*

Carbamazepine (Anticonvulsant Drugs)

Some patients with treatment-resistant bipolar disorder improve after taking carbamazepine (Tegretol) and lithium, or carbamazepine and an antipsychotic. Carbamazepine seems to work better in patients with rapid cycling and in severely paranoid, angry, patients experiencing manias than in euphoric, overactive, overfriendly patients experiencing manias. It is also thought to be more effective in dysphoric patients experiencing manias. As with valproate, liver function and platelet count should be monitored periodically. Blood levels of carbamazepine should be monitored at least weekly for the first 8 weeks of treatment, because the drug can increase levels of liver enzymes that can speed its own metabolism. In some instances, this can cause bone-marrow suppression and liver inflammation.

mood

The euphoric mood associated with mania is unstable. During euphoria, the patient may state that he or she is experiencing an intense feeling of well-being, is "cheerful in a beautiful world," or is becoming "one with God." The overly joyous mood may seem out of proportion to what is going on, and cheerfulness may be inappropriate for the circumstances. This mood may change quickly to irritation and anger when the person is thwarted. The irritability and belligerence may be short-lived, or it may become the prominent feature of the manic phase of bipolar disorder. People experiencing a manic state may laugh, joke, and talk in a continuous stream, with uninhibited familiarity. They often demonstrate boundless enthusiasm, treat others with confidential friendliness, and incorporate everyone into their plans and activities. They know no strangers, and energy and self-confidence seem boundless. Elaborate schemes to get rich and famous and acquire unlimited power may be frantically pursued, despite objections and realistic constraints. Excessive phone calls and e-mails are made, often to famous and influential people all over the world. People in the manic phase are busy during all hours of the day and night, furthering their grandiose plans. To the person experiencing mania, no aspirations are too high, and no distances are too far. No boundaries exist to curtail them. In the manic state, a person often gives away money, prized possessions, and expensive gifts. The person experiencing a manic episode may throw lavish parties, frequent expensive nightclubs and restaurants, and spend money freely on friends and strangers alike. This excessive spending, use of credit cards, and high living continue even in the face of bankruptcy. Intervention is often needed to prevent financial ruin.

cognitive functioning

The onset of bipolar disorder is often preceded by comparatively high cognitive function. However, there is growing evidence that about one third of patients with bipolar disorder display significant and persistent cognitive problems and difficulties in psychosocial areas. Cognitive deficits in bipolar disorder are milder but similar to those in patients with schizophrenia. Cognitive impairments exist in both bipolar I and bipolar II, but are more pronounced in bipolar I. The potential cognitive dysfunction among many people with bipolar disorder has specific clinical implications: •Cognitive function greatly affects overall function. •Cognitive deficits correlate with a greater number of manic episodes, history of psychosis, chronicity of illness, and poor functional outcome. •Early diagnosis and treatment are crucial to prevent illness progression, cognitive deficits, and poor outcome. •Medication selection should consider not only the efficacy of the drug in reducing mood symptoms but also the cognitive impact of the drug on the patient.

acute phase

The overall outcome is *injury prevention*. Outcomes in the acute phase reflect both physiological and psychiatric issues. For example, the patient will: •Be well hydrated. •Maintain stable cardiac status. •Maintain/obtain tissue integrity. •Get sufficient sleep and rest. •Demonstrate thought self-control. •Make no attempt at self-harm.

maintenance phase

The overall outcomes is to *continue to focus on prevention of relapse and limitation of the severity and duration of future episodes*. Relevant NOC outcomes include Knowledge: Disease Process, Compliance Behavior, and Family Support During Treatment. Additional outcomes include: •Participation in learning interpersonal strategies related to work, interpersonal, and family problems •Participation in psychotherapy, group, or other ongoing supportive therapy modality

self assessment

The patient experiencing mania (who is often out of control and resists being controlled) can elicit numerous intense emotions in a nurse. The patient may use humor, manipulation, power struggles, or demanding behavior to prevent or minimize the staff's ability to set limits on and control dangerous behavior. People with mania have the ability to staff split, or divide the staff into either the good guys or the bad guys. "The nurse on the day shift is always late with my medication and never talks with me. You are the only one who seems to care." This divisive tactic may pit one staff member or group against another, undermining a unified front and consistent plan of care. Frequent staff meetings to deal with the behaviors of the patient and the nurses' responses to these behaviors can help minimize staff splitting and feelings of anger and isolation. Limit-setting (e.g., lights out after 11 PM) is the main theme in treating a person in mania. *Consistency among staff is imperative if the limit setting is to be carried out effectively*. The patient can become aggressively demanding, which often triggers frustration, worry, and exasperation in health care professionals. The behavior of a patient experiencing mania is often aimed at decreasing the effectiveness of staff control, which could be accomplished by getting involved in power plays. For example, the patient might taunt the staff by pointing out faults or oversights and drawing negative attention to one or more staff members. Usually, this is done in a loud and disruptive manner, which provokes staff to become defensive and thereby escalates the environmental tension and the patient's degree of mania. If you are working with a patient experiencing mania, you may find yourself feeling helplessness, confusion, or even anger. Understanding, acknowledging, and sharing these responses and countertransference reactions will enhance your professional ability to care for the patient and perhaps promote your personal development as well. Collaborating with the multidisciplinary team, accessing supervision with your nursing faculty member, and sharing your experience with peers in post-conference may be helpful, perhaps essential.

behavior

When people experience hypomania, they have voracious appetites for social engagement, spending, and activity, even indiscriminate sex. Constant activity and a reduced need for sleep prevent proper rest. Although short periods of sleep are possible, some patients may not sleep for several days in a row. This nonstop physical activity and the lack of sleep and food can lead to physical exhaustion and even death if not treated; it therefore constitutes an emergency. When in full-blown mania, a person constantly goes from one activity, place, or project to another. Many projects may be started, but few if any are completed. Inactivity is impossible, even for the shortest period of time. Hyperactivity may range from mild, constant motion to frenetic, wild activity. Flowery and lengthy letters are written, and excessive phone calls are made. Individuals become involved in pleasurable activities that can have painful consequences. For example, spending large sums of money on frivolous items, giving money away indiscriminately, or making foolish business investments can leave an individual or family penniless. Sexual indiscretion can dissolve relationships and marriages and lead to sexually transmitted diseases. Religious preoccupation is a common symptom of mania. Individuals experiencing mania may be manipulative, profane, fault finding, and adept at exploiting others' vulnerabilities. They constantly push limits. These behaviors often alienate family, friends, employers, health care providers, and others. Modes of dress often reflect the person's grandiose yet tenuous grasp of reality. Dress may be described as outlandish, bizarre, colorful, and noticeably inappropriate. Makeup may be garish and overdone. People with mania are highly distractible. Concentration is poor, and individuals with mania go from one activity to another without completing anything. Judgment is poor. Impulsive marriages and divorces can take place.

Clonazepam (Klonopin) and lorazepam (Ativan)

are antianxiety (anxiolytic) drugs useful in the treatment of acute mania in some patients who are resistant to other treatments. *These drugs are also effective in managing the psychomotor agitation seen in mania*. They should be avoided, however, in patients with a history of substance abuse.

rapid cycling

four or more mood episodes in a 12 month period is used to indicate more severe symptoms, such as poorer global functioning, high recurrence risk, and resistance to conventional somatic treatments

overdose management

gastic lavage and treatment with urea, mannitol, aminophylline can hasten lithium excretion hemodialysis may also be necessary in extreme cases

acute phase (planning)

highest priority is always safety *Depressive episodes* Depressive episodes of bipolar disorder have the same symptoms and risks as major depression, although they are often more intense. Hospitalization may be required if suicidal ideation, psychosis, or catatonia is present. Lithium and lamotrigine (Lamictal) are the first line of treatment for a person with bipolar disorder experiencing an acute depressive episode . Treatment with antidepressants is not recommended (particularly for bipolar I disorder), since the patient's central nervous system (CNS) may become overactive, which results in hypomania or mania. Patients who experience depression while taking maintenance levels of medications may benefit from increased doses of the original drugs. When depressive episodes have psychotic features, an atypical antipsychotic may be added to the medication regimen. *Manic episodes* Hospitalization provides safety for a patient experiencing acute mania (bipolar I disorder), imposes external controls on destructive behaviors, and provides for medication stabilization. There are unique approaches to communicating with and maintaining the safety of the patient during the hospitalization period. Staff members continuously set limits in a firm, nonthreatening, and neutral manner to prevent further escalation of mania and provide safe boundaries for the patient and others.

Lamotrigine (Lamictal) (Anticonvulsant Drugs)

is a first-line treatment for bipolar depression and is approved for acute and maintenance therapy. ___ is generally well tolerated, but there is one serious but rare dermatological reaction: a potentially life-threatening rash. Patients should be instructed to seek immediate medical attention if a rash appears, although most are likely benign

continuation phase (implementation)

is crucial for patients and their families. The outcome for this phase is prevention of relapse, and community resources are chosen based on the needs of the patient, the appropriateness of the referral, and the availability of resources. Frequently a case manager evaluates appropriate follow-up care for patients and their families. *Medication adherence during this phase is perhaps the most important treatment outcome*. This follow-up is frequently handled in a mental health center. However, adherence to the medication regimen is also addressed in day hospitals and psychiatric home-care visits. Some patients may attend day hospitals if they are not too excitable and are able to tolerate a certain level of stimuli. In addition to medication management, day hospitals offer structure, decrease social isolation, and help patients channel their time and energy. If a patient is homebound, psychiatric home care is the appropriate modality for follow-up care.

Valproate (Depakote) (Anticonvulsant Drugs)

is useful in treating lithium nonresponders who are in acute mania, experience rapid cycles, are in dysphoric mania, or have not responded to carbamazepine. ___ is also helpful in preventing future manic episodes. It is important to monitor liver function and platelet count periodically, although serious complications are rare.

maintenance phase planning

planning focuses on maintaining adherence to the medication regimen and prevention of relapse. Interventions are planned in accordance with the assessment data regarding the patient's interpersonal and stress-reduction skills, cognitive functioning, employment status, substance-related problems, and social support systems. During this time, psychoeducational teaching is necessary for the patient and family. The need for referrals to community programs, groups, and support for any co-occurring disorders or problems (e.g., substance abuse, family problems, legal issues, and financial crises) is evaluated. Evaluation of the need for communication skills training and problem-solving skills training is also an important consideration. People with bipolar disorders often have interpersonal and emotional problems that affect their work, family, and social lives. Residual problems resulting from reckless, violent, withdrawn, or bizarre behavior that may have occurred during a manic episode often leave lives shattered and family and friends hurt and distant. For some patients, cognitive-behavioral therapy (in addition to medication management) is useful to address these issues, although the focus of psychotherapeutic treatment will vary over time for each individual.

maintenance phase (planning)

planning focuses on preventing relapse and limiting the severity and duration of future episodes. Patients with bipolar disorders require medications over long periods of time or even an entire lifetime. Psychotherapy, support groups, psychoeducational groups, and periodic evaluations help patients maintain their family, social, and occupational lives.

Assessment Guidelines Bipolar Disorder

•Danger to self or others •Need for protection from uninhibited behaviors •Need for hospitalization •Medical status •Coexisting medical conditions •Family's understanding

Lithium

•Elation, grandiosity, and expansiveness •Flight of ideas •Irritability and manipulation •Anxiety To a lesser extent •Insomnia •Psychomotor agitation •Threatening or assaultive behavior •Distractibility •Hypersexuality •Paranoia