BIPOLAR DISORDER

Bipolar disorder is a life-long mood disorder that causes intense shifts in mood (from mania to depression), energy levels, thinking patterns, and behavior. These shifts can last for hours, days, weeks, or months and interrupt the person’s ability to perform day-to-day tasks. Bipolar disorder affects approximately 5.7 million adult Americans every year, or about 2.6% of the U.S. population 18 and older. It is present in up to 4% of primary care patients (DBSA, 2023).

Signs and Symptoms of Bipolar Disorder

Mania is a period of abnormally elevated or irritable mood, as well as extreme changes in emotions, thoughts, energy, talkativeness, and activity level. People in this state often indulge in activities that result in physical, social, or financial harm. They often develop psychotic symptoms, including delusions and hallucinations, which can make it difficult to distinguish bipolar disorder from other psychotic disorders. Other signs and symptoms may include:

• Restlessness
• Rapid speech, racing thoughts, and poor concentration
• Distractibility
• Lack of insight
• Increased energy and less need for sleep
• Increased impulsivity and poor judgment
• Unusually high sex drive
• Feeling able to do many things at once without getting tired
• Grandiosity (claiming exaggerated and unrealistic abilities and achievements)

Depressive episodes in bipolar disorder are periods of low or depressed mood and/or loss of interest in most activities as well as other symptoms of depression, including fatigue, appetite changes, negative feelings of self-worth, and hopelessness (Cleveland Clinic, 2022a).

Treatment for Bipolar Disorder

Bipolar disorder is a complex, chronic condition that can be difficult to treat and that requires medications and psychotherapy. As a result, polypharmacy is commonplace, and many patients require multiple medications to control their symptoms effectively. It is important that clinicians become educated about the various side effects of the wide array of medications available for treatment and to be aware that the tolerability of these medications is one of the key reasons for noncompliance (Nasrallah & Kuo, 2022).

Medications prescribed for treatment of bipolar disorder include:

• Mood stabilizers
• Some anticonvulsants
• Antipsychotics
• Anxiolytics
• Antidepressants

Medical comorbidities are quite prevalent in patients with bipolar disorder due to the adverse effects of these medications. Regular monitoring of weight, glycemia, dyslipidemia, blood pressure, and liver function is necessary.

The gold standard for treating bipolar disorder is the mood stabilizer lithium carbonate. Lithium has a narrow range of safety, and blood tests are required before and at intervals during treatment with the drug. Clinicians should be aware that patients who are taking lithium carbonate are at risk for lithium toxicity, for which there is no antidote and which can cause death. It is also important for clinicians to be aware that there are 690 drugs known to interact with lithium (NAMI, 2021; Chokhawala et al., 2022; Drugs.com, 2022).

How to Respond to and Provide Care for a Patient with Signs and Symptoms of Bipolar Disorder

In contrast to patients with major depressive disorder, patients with bipolar disorder are more likely to present with racing thoughts and/or irritability when they are not depressed and are more likely to have suicidal thoughts during periods of depression. Patients with bipolar disorder should always be evaluated for suicide risk and acute or chronic psychosis.

The priority in caring for a patient with bipolar disorder is safety and the establishment of external controls. Patients with bipolar disorder experiencing a manic episode are at risk for injury and self-directed or other-directed violence. They have impaired social interactions, do not cope well, and may be unable to complete self-care (Martin, 2022a).

When involved in the care of a patient with bipolar disorder, it is true that some conduct associated with the disorder can be very difficult to contend with. However, it is necessary to remember that these behaviors are actually symptoms, the result of illness. It is also important to recognize some of the typical reactions clinicians may have toward persons with manic behaviors and to consider them during interactions. These can include:

• Amusement. It is easy to laugh and respond to the outrageous things a patient may say or do, but it is important to ensure that respect for the patient is maintained at all times.
• Irritation. Manic patients may be noncompliant with routines, rules, or personal healthcare. They often test limits. This can cause providers to feel irritated or even angry with such patients.
• Embarrassment. Some providers feel embarrassed at what is seen as the patient’s apparent lack of control. If the behavior occurs in front of others, providers may feel embarrassed that they cannot effectively intervene.
• Discomfort. The patient can be verbally abusive and can make personally demeaning comments to and about providers.

Effective ways to respond include:

• Be patient when attempting to communicate; do not rush or pressure the patient to talk.
• Answer questions briefly, quietly, calmly, and honestly.
• Counter distractibility and poor concentration by giving the patient clear, simple, and concrete instructions.
• Attempt to educate patients about the inappropriateness of their behavior without criticizing or blaming them.
• Avoid judging the person, and do not give negative feedback.
• Avoid verbal confrontations with the person, who is likely to have a low tolerance for debate.
• Do not try to appeal to the patient using logic, as the patient is not thinking rationally.
• Encourage the patient to respect the personal space of others.
• Provide consistent limits on behaviors and verbal abuse; make sure all staff are clear about these limits and that they reinforce them.
• Encourage and support any ideas the person has that are realistic and in keeping with their healthcare regimen. It is far more effective to suggest alternative strategies rather than to forbid an action.
• Encourage the person to organize and slow thoughts and speech patterns by focusing on one topic at a time and asking questions that require brief answers only.
• If a patient’s thoughts and speech become confused, cease the conversation and help to calm the patient by sitting quietly together.
• Limit the person’s interactions with others as much as possible, and remove any external stimulation where possible.

Nursing interventions include:

• Providing structured solitary activities to help the patient stay focused
• Providing frequent rest periods
• Promoting rest and sleep
• Monitoring intake, output, and vital signs
• Providing supervision when eating
• Maintaining clear and consistent limits and expectations to minimize potential for manipulation of staff
• Maintaining a low level of stimuli, which helps to minimize escalation of anxiety
• If the patient is taking lithium, observing for signs of toxicity
• Monitoring for side of effects of medications
• Redirecting aggressive or violent behaviors
  (Townsend, 2018; Martin, 2022a)