Assessing and Treating Patients with Bipolar Disorder

Assessing and Treating Patients with Bipolar Disorder

Bipolar disorders remain a global health concern. These disorders are a leading cause of disability and often present considerable management challenges to healthcare systems worldwide. Bipolar disorder is characterized by alternating manifestations of depressive and manic or hypomanic episodes. Bipolar II disorder is a stratiform of bipolar disorders that is predominantly depressive. Per the fifth edition of the Diagnostic and Statistical Manual for Mental Disorders (DSM-V), bipolar II diagnosis is made in the presence of one or more depressive episodes and at least an episode of hypomania lasting for four or more days(McIntyre & Calabrese, 2019). This paper details the assessment and treatment aspects of bipolar II disorders.

Prevalence and Neurobiology of Bipolar II Disorder

Bipolar II disorder, like other disorders in the bipolar spectrum, is a common mood disorder. It has a lifetime global prevalence of 0.5%. In the U.S., the prevalence stands at 0.8%. It affects all populations with little variations in gender, ethnicity, or socioeconomic status. The majority of persons with the disorders often manifest the symptoms before the age of 25. The onset of the disorder peaks between the ages of 15 to 24 and 45 to 54. The clinical course of the disease varies depending on the age of onset. In late-onset conditions, the rates of psychiatric and medical comorbidities such as suicidality tend to be higher (Rowland & Marwaha, 2018). This further highlights the need for aggressive management of the disorder.

Bipolar II disorder has a multivariate etiology. It is thought to be caused by an interplay of neurochemical, epigenetic, genetic, and environmental factors. Genetics have been implicated in the pathogenetic development of the disorder. Multiple genetic loci have been implicated in the development of the disorder. Specifically, changes in neurotrophin-3 and -4, brain-derived neurotrophic factor (BDNF), and nerve growth factors are apparent in the patients presenting with the disorder, indicating lowered neuroplasticity (McIntyre & Calabrese, 2019). Additionally, persons with close family members with the disease are highly likely to develop the disorder. Lifetime events such as childhood maltreatment, disability, unemployment, divorce, and other life stressors all interplay have been demonstrated in over 60% of the clients presenting with bipolar II disorder.

Differences between Bipolar II Disorder and other Disorders in the Bipolar Spectrum

Bipolar disorders are a spectrum of mood disorders consisting of multiple illnesses. These include bipolar I, bipolar II, cyclothymic disorder, specified bipolar and related disorders, and unspecified bipolar or related disorders. Bipolar I disorder, like bipolar II disorder, also presents with alternating manifestations of depressive and manic or hypomanic symptoms. Unlike bipolar II disorder, bipolar I disorder presents with more severe manic episodes with minimal depressive manifestations (Preuss et al., 2020). Cyclothymic disorder is a mood disorder characterized by hypomanic and depressive episodes. However, this condition does not meet the full criteria for bipolar or major depressive disorder as per the DSM-V criteria. Cyclothymic individuals tend to have emotional flare-ups with less severe symptoms than either bipolar I or II disorders. Other specified bipolar and related disorders, as per DSM-V, detail all bipolar-like manifestations that do not meet the criteria for the disease. In the comprehensive management of bipolar disorders, history-taking is necessary to rule out other disease involvements and to distinguish between bipolar disorder and related conditions.

Special Populations Considerations.

Bipolar II disorders affect all populations. However, some populations may be disproportionately affected. In the elderly population, bipolar disorders have far-reaching effects on the quality of life and the clinical outcomes of persons diagnosed with the disorder. Tampi et al. (2021) note that the rates of suicidality are higher among the elderly groups. Additionally, older adults with the disorder tend to experience more frequent episodes. This warrants an aggressive approach when managing this disorder in older groups.

A legal consideration when managing older adults with bipolar disorder is centered on voluntary hospitalization. As per the voluntary hospitalization and treatment statutes, patients have the right to willingly sign into a facility of care for the management of their illnesses. Older adults with bipolar tend to be at risk of self-harm due to the increased potential for suicidality. These patients may involuntarily be admitted to the institution of care in an attempt to preserve their health. An ethical consideration for this group is the preservation of autonomy. As per the principle of autonomy, patients have the right to make informed decisions about their health choices. This may, however, pose a dilemma where involuntary admission is perceived as necessary.

Bipolar disorder in children and teens is also of significant social and health concern. Children and teens with the disorder tend to perform poorly in school and develop socially due to difficulties in getting along with others and the normative school curriculum. Some also tend towards self-harm behaviors such as suicide. The diminished ability of children to express themselves and seek care also warrants close supervision of those at risk of the disorder.

A legal consideration when managing children and adolescents with bipolar is confidentiality. As per the legal precinct, caregivers are obliged to maintain patient confidentiality. However, this legal angle may be challenged where self-harm is apparent. Due to the high potential of teens to engage in self-harm behaviors, caregivers preserve the duty to make a sound clinical judgment on whether to preserve this legal obligation. An ethical consideration in the management of adolescents and children with bipolar is the duty to do good to the patients per the ethical principle of beneficence. Beneficence requires that caregivers protect the welfare of their patients. In this respect, protecting the welfare of the patients may translate to sharing confidential information that may suggest the intent to harm others or oneself.

Specific consideration should also be made for pregnant and breastfeeding women, and those receiving emergency care. Women with bipolar disorder are sometimes at high risk for postnatal depression and postpartum psychosis. This may exacerbate their conditions and result in poor clinical outcomes. It is thus necessary that birthing women are monitored closely for these conditions. Those in emergency care are already impacted by their incarceration along with other underlying illnesses. Conditions such as bipolar may further exacerbate their conditions, leading to poor health outcomes. Close supervision of patients in these population groups is thus necessary.

Legal considerations when managing birthing women and those in emergency care are bordered on decisions or preferences of treatment and autonomy. Legally, women and those receiving emergency treatment preserve the right of choice regarding treatment options applied to them. Ideally, the patient’s preferences are observed. However, whatever may be best for the patient may not be the ideal option in managing the presenting case. This may present an ethical and legal dilemma to the caregivers. Caregivers maintain the legal obligation to respect the patient’s decision. Their role in this regard is to inform the patient of the available options and allow them to make an informed choice of the therapeutic modality to be applied to them. An ethical obligation when caring for birthing women and those in emergency care is the duty to do no harm and protect the welfare of the patients. Caregivers, in this regard, are expected to engage in activities that better guarantee the overall wellness of their patients. This includes monitoring their patients and delivering the best care to them.

FDA and/or Clinical Practice Guidelines 

Comprehensive management of bipolar disorders utilizes a pharmacotherapeutic approach involving various medications. A consensual finding on various therapeutic guidelines recommends selecting a therapeutic modality based on the manifested episode. Manic episodes are considered as medical emergencies and often warrant psychiatric hospitalization. The initial approach to managing mania is targeted at stabilizing the client to allow for assessment. Benzodiazepines such as diazepam are used concomitantly with mood stabilizers such as sodium valproate, and antipsychotic medications such as risperidone can be used to lessen agitation and calm the patient.

Hypomanic episodes can be managed in the outpatient setup. Low-dose sodium valproate is used in the management of hypomania. Antipsychotic medications such as aripiprazole can also be used where mood stabilizers are inappropriate.

Depressive episodes are managed using antipsychotic medications. Psychiatric hospitalizations may be necessitated in acute depression and where the risk of suicide is higher. For patients not on long-term therapy for bipolar disorder, first-line monotherapy with antipsychotic medications may help in alleviating depressive episodes. Combination treatment using a selective serotonin reuptake inhibitor, such as fluoxetine and olanzapine, may also help alleviate depressive episodes. Cognitive behavioral therapy may be included as an add-on therapy for patients with bipolar depression. This modality maintains effectiveness in alleviating mild to moderate depression.

Maintaining therapy is necessary for all patients with bipolar II disorder. The maintenance phase helps in preventing the recurrence of episodes and may restore pre-illness functioning. Mood stabilizers and atypical antipsychotic medications used alone or in combination are the available options in the maintenance therapy for bipolar disorder (Jain et al., 2022). Integral to maintenance therapy is medication adherence, prevention of comorbidities, and psychotherapy. These interventions may help in preventing recurrences and in optimizing the functionalities of patients with bipolar disorders.

Lithium is a mood stabilizer effective in managing bipolar II disorders. It is FDA-approved in the acute and maintenance phases of bipolar II disorder but may also be used in other forms of bipolar disorder. It has been associated with reduced suicidality. The side effects of lithium include GI disturbances, goiter, nephrogenic diabetes, and bradycardia, among others. It should be contraindicated in patients with known hypersensitivity and renal impairment (Volkmann et al., 2020). Lithium is not recommended for patients with cardiovascular disease, pregnant women, and breastfeeding mothers. As a standard of care, monitoring for lithium serum levels is necessary. This medication has a narrow therapeutic index. Specific lab measures that are essential in therapy with lithium include kidney function and thyroid function tests due to the potential of this medication to cause nephrogenic diabetes and goiter (Volkmann et al., 2020). Monitoring for comorbidity with diabetes and dyslipidemia is necessary as this medication may exacerbate these conditions.

How to Write a Prescription of Lithium

A typical lithium prescription should include detailed patient information, the indication for which it is prescribed, the date, the name of the drug, its dosage and duration of therapy, and the name of the prescriber. The first way to write a lithium prescription includes writing by brand name. This is important as various brands vary in bioavailability. Lithium prescriptions can also be written based on the intent of therapy. For the initial phase, higher doses may be used, while for the maintenance phase, lower doses are used. The third way to write a lithium prescription is writing while detailing specific information such as the contraindications and other warnings on the toxicological profile of the medications.

 References

Jain, R., Kong, A. M., Gillard, P., & Harrington, A. (2022). Treatment patterns among patients with bipolar disorder in the United States: A retrospective claims database analysis. Advances in Therapy, 39(6), 2578–2595. https://doi.org/10.1007/s12325-022-02112-6

McIntyre, R. S., & Calabrese, J. R. (2019). Bipolar depression: The clinical characteristics and unmet needs of a complex disorder. Current Medical Research and Opinion, 35(11), 1993–2005. https://doi.org/10.1080/03007995.2019.1636017

Preuss, U. W., Hesselbrock, M. N., & Hesselbrock, V. M. (2020). A prospective comparison of bipolar I and II subjects with and without Comorbid Alcohol Dependence from the Coga dataset. Frontiers in Psychiatry, 11. https://doi.org/10.3389/fpsyt.2020.522228

Rowland, T. A., & Marwaha, S. (2018). Epidemiology and risk factors for bipolar disorder. Therapeutic Advances in Psychopharmacology, 8(9), 251–269. https://doi.org/10.1177/2045125318769235

Tampi, R. R., Joshi, P., Bhattacharya, G., & Gupta, S. (2021). Evaluation and treatment of older-age bipolar disorder: A narrative review. Drugs in Context, 10, 1–12. https://doi.org/10.7573/dic.2021-1-8

Volkmann, C., Bschor, T., & Köhler, S. (2020). Lithium treatment over the lifespan in bipolar disorders. Frontiers in Psychiatry, 11. https://doi.org/10.3389/

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For this assignment, you will write a 5–6-page paper on the topic of bipolar and bipolar and related disorders. You will create this guide as an assignment; therefore, a title page, introduction, conclusion, and reference page are required. You must include a minimum of 5 scholarly supporting resources outside of the resources provided by your course.

Assessing and Treating Patients with Bipolar Disorder

In your paper, you will choose one of the following diagnoses: Bipolar I, Bipolar II, Cyclothymic Disorder, Substance/Medication-Induced Bipolar and Related Disorder, Bipolar and Related Disorder Due to Another Medical Condition. Your paper will include a discussion of your chosen diagnosis of bipolar and related disorders on the following:

Prevalence and Neurobiology of your chosen disorder
Discuss the differences between your chosen disorder and one other bipolar and related disorder in relation to the diagnostic criteria, including the presentation of symptoms according to DSM 5 TR criteria.
Discuss special populations and considerations (children, adolescents, pregnancy/post-partum, older adult, emergency care) for your chosen bipolar and related disorder, demonstrating critical thinking beyond the basics of HIPPA and informed consent with a discussion of at least one for EACH category: legal considerations, ethical considerations, cultural considerations, social determinants of health.
Discuss FDA and/or clinical practice guidelines approved pharmacological treatment options in relation to acute and mixed episodes vs maintenance pharmacological treatment for your chosen bipolar and related disorder.
Discuss the medication treatment options for your chosen disorder, as well as side effects, FDA approvals, and warnings. What is important to monitor in terms of labs, comorbid medical issues, and why is it important for monitoring
Provide 3 examples of how to write a proper prescription that you would provide to the patient or transmit to the pharmacy.