Mood Disorders: Bipolar I and II
Learning Objectives
1.Discuss types of mood disorders: Depression, Bipolar Disorder
2.Describe signs and symptoms of mood disorders
3.Discuss treatment approaches for mood disorders
4.Explain mechanism of action, common side effects and nursing
considerations related to medications used to treat mood
disorders.
5.Use the nursing process to assess and formulate nursing
diagnoses and care interventions and teaching for a client with
a mood disorder.
6.Articulate the care of the client undergoing electroconvulsive
therapy (ECT).
What is Bipolar Disorder?
• The 2 “poles” are mania and
depression
• Affects men and women equally
• No single gene identified, but a
strong genetic component
• Can start in childhood or
throughout adulthood
Mania BP I
• VERY elevated mood for at least 1 week, not attributed to other causes meds,
substances etc.
• Episodic
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Inflated self-esteem, grandiosity
Decreased need for sleep
Very talkative
Flight of ideas, racing thoughts
Easily distracted
Increased goal-directed activity, agitation
Risky behavior, poor judgment
May include psychosis
• Mood disturbance causing social, work, or interpersonal problems
• May need hospitalization
Hypomania “Manic Lite” BP II
Same symptoms but less severe than mania
• At least 4 days’ duration
• Not severe enough to warrant hospitalization
• Persistent elevated expansive or irritable mood
• NEVER psychosis
• Symptoms don’t cause major effects on functioning
Depressive Episode BP I and II
• Unable to focus or concentrate
• Thoughts of death and suicide
• Excessive sleepiness
Mixed Episode
• Person may have features of
both mania and depression at
the same time to varying
degrees
• Marked impairment in
functioning
Cyclothymic Bipolar
• Rapid Cycling
• Swing between a hypomanic episode and depressive symptoms
• Symptoms have occurred for at least 2 years
• Symptoms have occurred without remission for more than 2 months
Bipolar I
• Bipolar I – Most Serious
• Symptoms: one episode of
MANIA !!!! alternating with one
episode depression.
• May include Psychosis
Bipolar II
• Bipolar II – More Common
• Symptom: one or more
hypomanic episodes alternating
with depressive episodes
• No full mania or psychosis
What Bipolar is not…
• Moodiness
• A Personality Disorder
• An Adjective
Assessment, Diagnosis and Treatment
• Diagnosis based on symptoms meeting DSM-5 criteria
• Ask about caffeine, energy drinks, alcohol, steroids, medications including OTC and Illicit drugs
• Ask about medical conditions
• Assess appearance, thoughts, speech, affect, judgment, behavior
• Is it Bipolar ? Misdiagnosis is common
• Biological
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Medications
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Stabilize mood
Dampen mania
Alleviate depression
Treat psychosis (delusions, hallucinations)
• Psychological
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Supportive therapy
May “dig deep”
Helps people to deal with the devastation that their manic behavior has wrought
ECT
Pharmacology: Mood Stabilizing Drugs
First line Treatments
• LITHIUM treatment of choice for controlling mania in bipolar disorder
• Anticonvulsants (Lamotrogine, Valproate and Depakote)
• Antipsychotics (mostly SGA) second generation antipsychotics
• Benzodiazepines
• Antidepressants can be used but with caution!
Pharmacology Examples
• Acute Mania
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Drugs: Lithium carbonate (Eskalith, Lithobid)
Must be compliant, requires labs and lifestyle changes
Risk of OD and Toxicity
Common Side Effects: fine hand tremors, GI upset, polyuria (Diabetes
Insipidus), wt gain, Hypothyroidism, Wt gain, kidney toxicity, electrolyte
imbalance , leukocytosis
• Think LITH ( Leukocytois, insipidus, Tremors, Hypothyroidism)
Labs – Lithium (CRITICAL)
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Plasma - Lithium Toxicity level
BUN and Creatinine
Hypothyroidism - TSH levels rise when T3 & T4 is low
Hypothyroidism - TSH levels rise when T3 & T4 is low
TSH (T3 and T4), TSH range 2-10 mu/l
Check Na+ need sodium to keep lith levels
• AVOID DIURETICS ! Get rids of Na+ and Water, no NSAID too hard on kidneys
• 100 % eliminated by kidney
• Avoid in Renal disease.
Nursing Responsibilities: Lithium
• Lithium levels monitored due to the narrow window between
therapeutic and toxic!! 1.5 mEq/L
 Therapeutic range 0.6 – 1.2 mEq/L (varies by textbook, keep range around
1.0 mEq/L)
 Inpatient check labs prior to administration
 Labs within 5 days of starting drug, weekly, then monthly, 3, 6 – 12 mos
 Labs if dosage increases/ Labs if behavior changes
 Labs in a.m. 8-12 hours after last dose
 Older adults, very thin clients - start low, go slow
 Fluids important, Food Important (mania/depression), Assess labs
Lithium Toxicity !!!
• Ensure adequate salt intake
• Decreased sodium in the body can increase risk of lithium toxicity
Symptoms:
Moves from mild to COARSE Hand tremors, blurred vision, ataxia, SEVERE NV
diarrhea, psychomotor retardation, mental confusion, coma, cardiovascular
collapse.
Treatment:
Stop drug, call provider, gastric lavage, hemodialysis
Anticonvulsants to Treat Bipolar
• Lamotrogine (Lamictal)
• Carbamazepine (Tegretol) Black Box Warning !
• Can cause blood dyscrasia (anemia, leukopenia, thrombocytopenia),
vision problems, SIADH – syndrome of inapproraiet ADH - causes
retention of water and dilutes blood, skin rash.
• CBC, infection (WBC may be low)
Anticonvulsant
• Valproic Acid (Valproate)
• Black Box Warning
• Hepatotoxcity, pancreatitis, GI upset, Thrombocytopenia, Neural tube
defects in developing fetus
• Labs:
• LFT, ALT, AST, bilirubin – hepatotoxicity
Anticonvulsant - Lamotrogine (Lamictal) Black Box Warning
Steven Johnson Syndrome
Side Effects
• Blurred vision
• Decreased appetite
• Irregular HR/ RR
• Decreased urine output
• NV
• Poor motor coordination
• *seizures
• STOP MED !
Nursing Assessment
• Obtain medical and mental health history
• Assess symptoms: subjective and objective data
• Assess physical health (re: assess underlying health problems ie: HTN, new or
healed scars and bruises, hair pulling, agitation, appearance, weight.
• Evaluate lab data: urine drug screen, pregnancy test, BUN and creatinine, liver
function, electrolytes / chem profile, CBC and BG.
• Assess: ADL’s, sleep, nutrition, musculoskeletal, neurological, GI, GU,
reproductive.
• Assess: mood, affect and behaviors.
• Assess: culture/diet/health care practices/rituals/alternative medicines/language
• Assess suicide risk- intent, plan, access to lethal methods, and acts of
deceptiveness related to suicide.
Nursing Interventions: Bipolar Disorders
• Matter-of-fact tone
• Clear, concise directions and
comments
• Limit setting
• Remain calm
• Avoid arguing and debating
• SUICIDE RISK HIGH
• Safety
• Staff consistency
• Reduce environmental stimuli
• Do not escalate patients
• Reinforce appropriate hygiene,
dress
• Monitor nutrition and sleep
• Establish routines
Risk Assessment
• Patients with Mood disorders are at high risk for:
• Suicidal thoughts and suicide
• Substance abuse
• Ineffective coping
• Physical illness
 Assessment, monitoring and evaluation of each patient is critical!
Nursing Diagnosis
• Alteration in thought processes
• Ineffective Individual Coping
• Alterations in Family Relationships
• Risk for Self Harm
• Risk for Violence
• Imbalanced Nutrition
• Sleep deficit
• Spiritual Distress
Nutrition and Sleep
• Provide food to eat on the run
• Provide high-protein, highcalorie snacks
• Provide daily multivitamins
• Weigh regularly
• Provide quiet environment for
sleep
• Structure to avoid stimulating
activities during evening
• Reduce caffeine intake,
especially in evening
• Assess sleep-rest patterns
Patient Teaching
• Illness
• Signs of relapse
• Medication (need to understand meds and side effects, compliance
with meds critical!)
• Coping with symptoms
• Providing support
• Cognitive Behavioral Therapy/ Psychotherapy/ Individual/Group
Other medications for Acute Mania
• Seroquel (atypical antipsychotic)
• Depakote (anticonvulsant)
• Tegretol (anticonvulsant)
• Risperidal (atypical antipsychotic)
• Latuda (atypical antipsychotic)
• Saphris (atypical antipsychotic)
• Abilify (atypical antipsychotic)
• Invega (atypical antipsychotic) INJ
• Vraylar (atypical antipsychotic)
Acute Bipolar Depression
• Seroquel (atypical antipsychotic)
• Latuda and Lithium (atypical antipsychotic / mood stabilizer combo)
• Latuda and Depakote (atypical antipsychotic / anticonvulsant combo)
• Lithium (can treat both mania and depression, BEST for mania)
• Lamotrigine (can treat both mania and depression, BEST for
hypomania and depression)
• Maintenance meds: Lithium, Saphris, Depakote, Seroquel, Abilify,
Lamotrigine
Questions?
Professor Lang email cslang@gwu.edu