Assessing and Treating Patients with Bipolar Disorder
Bipolar disorder is a mood disorder that causes the affected person to have mood fluctuations of highs and lows. These “highs” are called mania, and these “lows” are called depression or depressive episodes. There are several types of bipolar disorder: bipolar I disorder, bipolar II disorder, cyclothymic disorder, substance/medication-induced bipolar and related disorder, and bipolar and related disorder due to another medical condition (National Institute of Mental Health, 2022). The purpose of this paper is to identify the prevalence and neurobiology of bipolar I disorder, identify the differences between bipolar I and bipolar II disorder, consider special populations, discuss FDA-approved treatment, and explore medications for the treatment of bipolar I disorder.
Prevalence and Neurobiology of Bipolar I Disorder
The prevalence of bipolar disorders is 1-4% (Harrison et al., 2018). In patients who have been diagnosed with bipolar disorder, there is no one common gene or one concrete “cause.” There are, however, similarities between patients with this diagnosis. Post-mortem studies have found decreased density or morphology of oligodendrocytes, which are the myelinating cells of the nervous system. Neuroimaging has found differences in the structures of the brains of those with bipolar disorder. Some of these differences include the increased volume in the striatum and amygdala. Functional studies have demonstrated greater activation in the brains of those with bipolar disorder than in the control. There have been some notable changes in the neurochemicals of those with bipolar disorder, such as a decrease in N-acetyl aspartate, an increase in choline, and changes in lactate, glutamate, and gamma-aminobutyric acid. (Perlis & Ostacher, 2016).
Differences in Bipolar I and Bipolar II Disorder
Bipolar I and Bipolar II disorders are similar in that they are both mood disorders characterized by highs and lows in moods. They do, however, differ in how these highs and lows affect the patient. Bipolar I disorder is often diagnosed after or during a manic episode. These episodes can be followed by major depressive episodes. Manic episodes must last at least one week (or result in hospitalization) and have three of the following symptoms (unless the predominant effect is irritable, then four are required): inflated self-esteem or grandiosity, decreased need of sleep, more talkative than usual, racing thoughts, distractibility, excess pleasurable risky activities. The manic mood must also cause an issue in functioning and not be attributable to a substance or medical condition. According to the DSM-5, the diagnosis criteria for bipolar I disorder must have one episode of mania in their lifetime (Perlis & Ostacher, 2016). Bipolar II disorder is often diagnosed after or during a major depressive episode. Major depressive episodes are defined as a depressed mood or loss of interest a majority of the time with changes in sleep, appetite, poor self-esteem, guilt, fatigue, poor concentration, psychomotor slowing, and suicidal thoughts. These episodes can be followed by hypomania. Hypomanic episodes are characterized by similar standards as manic episodes but are less severe. They are elevated from the patient’s baseline and must last for four days, be observable by others, but no not have to cause a significant impairment of functioning. Bipolar II diagnosis criteria include at least one hypomanic episode and one depressive episode, but this diagnosis excludes manic episodes. Patients with bipolar II disorder may experience more rapid mood cycling than patients diagnosed with bipolar I disorder (Perlis & Ostacher, 2016).
Special Populations and Considerations
Although the criteria are the same or very similar across the population for diagnosing bipolar disorder, each population may have differing symptoms. Children may have more rapid cycling. The symptoms may be explained as extreme versions of normal behaviors. Proactive treatment for those with a first-degree relative may be beneficial for children. The treatment regimens are similar but in pediatric dosages (Abrams, 2020).
Older adults may have symptoms that are overlooked. These symptoms may be explained away by “old age.” Older adults also tend to have several comorbidities, and these can influence treatment options. For instance, renal insufficiency and the effects of antipsychotics can call for special dosages. Diabetes as a comorbidity can also influence some medication choices due to hyperglycemia as a medication side effect. Services may also not be geared toward the elderly, leaving them “left out” of treatment options (Ljubic et al., 2021).
Legal and Ethical Considerations
Legal and ethical considerations are different and the same. Legally and ethically, the patient cannot be treated without their consent. Patient information can also not be shared without their consent. These both need to be expressed to the patient. The patient must be informed of all of the benefits and risks of the treatment, especially with some of the medications being prescribed. In addition, since family is so important in the consistency of treatment for those with bipolar disorder, there may need to be some communication between providers and family. Only the information that the patient wants releasing and to whom they want it to be released must be followed in accordance with HIPAA laws. Additionally, since patients experience such highs and lows associated with bipolar disorder, patients may need to be committed to their safety. The possibility of inpatient treatment may need to be discussed with the patient, whether it be voluntary or involuntary. Legal troubles may also present themselves for those with bipolar disorder. Manic episodes may lead the patient to engage in risky behavior, resulting in legal issues.
Cultural Considerations
Regardless of the push to end the stigma of mental health, there are still many who feel ashamed or embarrassed by their diagnosis. There are many cultures that do not believe in mental health or ones that do not accept it well or fully. When educating patients and their families, this must be thought about. How much do they know about this diagnosis? How does their culture support them in their mental health journey? What are the attitudes of their culture towards mental health?
Social Determinants of Health
Those with mental illness statistically suffer in the areas of social determinants of health. This patient may be unemployed, employed in undesirable jobs, or not have dependable employment. Lack of employment often leads to a lack of funds and, thus lack of ways to provide for oneself. Poor mental health has also been noted in those with lower incomes compared to higher incomes. This may mean that the patient suffers from lack of running water, lack of electricity, and the inability to buy food. This, in turn, also leads to poorer mental health outcomes (Alegría et al., 2018).
FDA and Clinical Practice Guidelines and Medication Treatment Options
Medications FDA-approved to treat bipolar disorder include mood stabilizers and antipsychotics (U.S. Food & Drug Administration, 2017). As with all new pharmacologic therapies, one drug at a time should be started, with more to add as necessary. If the patient responds to one drug, it is always best to use the least possible. It is also easier to see which drug is working the best or has negative side effects. For monotherapy, the patient would be prescribed Risperidone 3 mg PO daily, Lamotrigine 200 mg PO daily, or Lithium 0.8. mg daily, depending upon patient presentation. Risperidone would be prescribed for manic and mixed. episodes (Hirschfeld, n.d.). Lamotrigine or Lithium would be prescribed for maintenance. In addition, it would be recommended that the patient enrolls in psychotherapy, particularly family-focused therapy (American Psychiatric Association, 2010).
Many medications come with side effects, and the medication used to treat bipolar disorder comes with potentially dangerous side effects. Risperidone’s most common side effects are somnolence, increased appetite, fatigue, upper respiratory infection, vomiting, coughing, urinary incontinence, saliva increase, constipation, fever, dystonia, anxiety, nausea, dizziness, dry mouth, tremor, rash, akathisia, and dyspepsia. Patients with diabetes must be careful with risperidone because it may induce hyperglycemia. Routine blood glucose monitoring must be done. Leukopenia, neutropenia, and agranulocytosis may occur while taking risperidone, and CBC monitoring should be done routinely as well, one month after and every six months after that. Seizures, orthopnea, and increased suicide risk may also occur while taking risperidone (U.S. Food & Drug Administration, n.d.).
Lamotrigine may induce nausea, insomnia, somnolence, back pain, fatigue, rash, rhinitis, abdominal pain, and dry mouth. It may be potentially dangerous to an unborn child, so those who are pregnant or may become pregnant may need to weigh the risks and benefits of this medication. Additionally, estrogen-containing birth control may reduce the efficacy. Rashes may occur with it, and thrombocytopenia, pancytopenia, and neutropenia may occur, which can make infections more likely. CBCs may need to be monitored after the first month of treatment and every six months after (U.S. Food & Drug Administration, n.d.).
Lithium side effects can include tremors, seizures, slurred speech, dizziness, somnolence, restlessness, arrhythmia, hypotension, nausea, vomiting, diarrhea, and many more serious side effects. Lithium toxicity can occur, and routine lithium levels must be conducted. Toxicity can occur at levels that are very close to therapeutic. Patients who are pregnant do not need to take Lithium because it can cause harm to the fetus. Renal and cardiac insufficiency is also a contraindication to lithium use. Additionally, patients should have these labs monitored. A CBC and renal panel should be monitored after one month of therapy and every six months thereafter (U.S. Food & Drug Administration, n.d.).
Patients with bipolar disorder rarely have a BPD diagnosis exclusively. Often, BPD is compounded with other mental health disorders such as anxiety, PTSD, panic disorder, and substance abuse disorders. Patients with BPD must also be watched closely for psychosis and suicidality due to the higher rates of these in patients with this diagnosis (Perlis & Ostacher, 2016). These conditions may also complicate medication management or warrant the use of additional medication to treat these conditions acutely or in addition to BPD.
Prescriptions
Doe, Patient 8/11/90
123 Anywhere Else Ln. Jonesboro, AR 72401
Risperidone 3 mg by mouth every morning for bipolar I disorder Quantity: 30
Refills: 0 9/29/2022
Prescriber: Paige Bellinger NPI: 1234567890 123 Anywhere Ln. Jonesboro, AR 72401 Paige Bellinger (signature)
Doe, Patient 8/11/90
123 Anywhere Else Ln. Jonesboro, AR 72401
Lamotrigine 200 mg by mouth every morning for bipolar I disorder Quantity: 30
Refills: 0 9/29/2022
Paige Bellinger NPI: 1234567890
123 Anywhere Ln. Jonesboro, AR 72401
Paige Bellinger (signature)
Doe, Patient 8/11/90
123 Anywhere Else Ln. Jonesboro, AR 72401
Lithium 0.8 mg by mouth every morning for bipolar I disorder Quantity: 30
Refills: 0 9/29/2022
Paige Bellinger NPI: 1234567890
123 Anywhere Ln. Jonesboro, AR 72401
Paige Bellinger (signature)
References
Abrams, Z. (2020). Treating bipolar disorder in kids and teens. Monitor on Psychology, 51 (7), https://www.apa.org/monitor/2020/10/ce-corner-bipolar#:~:text=The%20criteria %20used%20to%20diagnose,involve%20periods%20of%20elevated%20mood%2C Alegría, M., NeMoyer, A., Falgàs Bagué, I., Wang, Y., & Alvarez, K. (2018). Social
Determinants of Mental Health: Where We Are and Where We Need to Go. Current psychiatry reports, 20(11), 95. https://doi.org/10.1007/s11920-018-0969-9
American Psychiatric Association. (2010). Practice guidelines for the treatment of patients with bipolar disorder (2nd ed.). https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/bipolar .pdf
Harrison, P. J., Geddes, J. R., & Tunbridge, E. M. (2018). The Emerging Neurobiology of Bipolar Disorder. Trends in neurosciences, 41(1), 18–30. https://doi.org/10.1016/j.tins.2017.10.006
Hirschfeld, R. M. A. (n.d.). Guideline watch: Practice guidelines for the treatment of patients with bipolar disorder (2nd ed.). https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/bipolar -watch.pdf
Husain, M.I., Chaudhry, I.B., Rahman, R.R. et al. A pilot study of a culturally adapted psychoeducation (CaPE) intervention for bipolar disorder in Pakistan. (2017). Int J Bipolar Disorder (5)3. https://doi.org/10.1186/s40345-017-0074-8
Ljubic, N., Ueberberg, B., Grunze, H. et al. (2021). Treatment of bipolar disorders in older adults: a review. Ann Gen Psychiatry 45 (20). https://doi.org/10.1186/s12991-021-00367- x
National Institute of Mental Health. (2022, September). Bipolar disorder. https://www.nimh.nih.gov/health/topics/bipolar-disorder
Perlis, R. H., & Ostacher, M. J. (2016). Bipolar disorder. In T. A. Stern, M. Favo, T. E. Wilens, & F. Rosenbaum. (Eds.), Massachusetts General Hospital psychopharmacology and neurotherapeutics (pp. 48–60). Elsevier.
U.S. Food & Drug Administration. (2017, March 28). The Facts on Bipolar Disorder and FDA-Approved Treatments. https://www.accessdata.fda.gov/scripts/cder/daf/index.cfm
U.S. Food & Drug Administration. (n.d.). Drugs@FDA: FDA-approved drugs. https://www.accessdata.fda.gov/scripts/cder/daf/index.cfm
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Question 
ASSESSING AND TREATING PATIENTS WITH BIPOLAR II DISORDER AND DIABETES TYPE 1.
For this Assignment, as you examine the patient case study in this week’s Learning Resources, consider how you might assess and treat patients presenting with bipolar disorder.
Assessing and Treating Patients with Bipolar Disorder
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 3 scholarly supporting resources outside of your course-provided resources.
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 ( Bipolar II and Type 1 Diabetes)
Discuss the differences between your chosen disorder and one other bipolar and related disorder in relation to the diagnostic criteria, including 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
Of the medication treatment options for your chosen disorder, discuss side effects, FDA approvals, and warnings. What is important to monitor in terms of labs and comorbid medical issues, with why is it important for monitoring? (use Escitalopram for Bipolar II and Insulin for Diabetes Type 1