Bipolar Disorder and

Treatments
Kristina Macdonald,
Amy MacHarg,
Tabitha Mason,
Angela Mcfalls,
Jessica McMichael
 Bipolar Disorder’s Criteria

 According to the American

Psychiatric Association’s
Diagnostic and Statistical
Manual of Mental Disorders,
fourth edition (DSM-IV);
“Bipolar Disorder is
characterized by the
occurrence of one or more
Major Depressive Episodes
accompanied by at least one
Manic Episode.”
 What Is Bipolar Disorder?

 A mood disorder that alters:

Feelings
Thoughts
Behaviors
Perceptions
(Within episodes of mania and depression)
 Bipolar Disorder is previously known as Manic Depression
 Clinical Presentations

 Most commonly
diagnosed between
ages of 18 and 24
 Mania, Hypomania,
Psychosis, depression
 Characteristics of Mania

 Feeling of being able to do anything

 Little sleep is needed
 Feeling filled with energy
 Not caring about financial situations
 Delusions
 Substance abuse
 The DSM-IV has a list of symptoms and three or more must be
present.
 Characteristics of Hypomania

 Feeling of creativity
 Don’t worry about problems seriously
 Feeling as if nothing can bring you down
 Have confidence in yourself

 Similar to Mania except Hypomania is of lesser intensity

 Characteristics of Psychosis

 Poor attention and concentration

 Suspiciousness
 Social withdrawal
 Feeling that things around you have changed

 Describing the diagnosis with psychosis is usually used to

clarify the severity of the state of the disorder
 Characteristics of Depression

 Sleep more than you normally would

 Feeling of tiredness
 Crying uncontrollably
 Withdrawing from activities you once enjoyed
 Staying in bed for days
 Weight Loss/Weight Gain
 The DSM-IV has a list of symptoms and five or more must be
present during the same two week period.
The Two Sides of Bipolar Disorder

 Bipolar I  Bipolar II
 Episodes of full mania  Episodes of major
alternating with depression and
episodes of major hypomania
depression
 Diagnosed in patients
typically in early 20’s
 Evaluation of Patient

 Make sure no other medical condition is causing

mood or thought disturbance
 Perform a physical examination
– Look for possibility of substance abuse
– Trauma to brain
– Seizure disorders

 Perform mental health evaluation

– Mental status examination (MSE)
 Assesses mood and cognitive abilities

 Safety of individual

 Examines forms of psychosis

 Evaluation of Patient Cont…

 Subjective experience of patient

 Family’s psychiatric history
 Prevalence

 Lifetime= 1%
 Males and Females = no difference
 Age = all ages
– Highest prevalence is in the 18 to 24 year age group

 First degree relatives = incidence of BP increases

 Affects roughly 1/100 adults
 Very little data about kids and teenagers
 Linked to disturbed electrical activity in the brain
 (Griswold, 2000)
 Bipolar Disorder

Difficulties
(Griswold, 2000)

Children Adolescents Pregnancy

Symptoms similar to adults

Psychosis can be a Planning of pregnancy is a
Hyperactivity is most
Presentation of BP. Necessity because of
Common; Makes BP
Substance abuse can be Medication
Difficult to diagnose
Present which makes Rapid cycling could occur
Diagnosis difficult
What Causes Bipolar?

 No single cause may ever be found for bipolar

disorder. Among the biological factors observed in
bipolar disorder, as detected by using imaging cans
and other tests, are the following:
– Over secretion of cortisol, a stress hormone.
– Excessive influx of calcium into brain cells.
– Abnormal hyperactivity in parts of the brain associated with
emotion and movement coordination and low activity in
parts of the brain associated with concentration, attention,
inhibition, and judgment. (Well Connected, 2002)
How Serious is Bipolar Disorder?

According to Well-Connected, 2002:

 Risk for Suicide
– An estimated 15-20% of patients who suffer from bipolar
disorder and do not receive medical attention commit
suicide.
 In a 2001 study of Bipolar I disorder, more than 50% of
patients attempted suicide; the risk was highest during
depressive episodes.
 Patients with mixed mania, and possible when it is marked by
irritability and paranoia, are also at particular risk.
 Many young children with bipolar disorder are more severely ill
than are adults with the disorder. According to a study in 2001,
25% of children with the disorder are seriously suicidal.
Seriousness of Disorder Cont.

 Thinking and Memory Problems

– In a 2000 study, it was reported that bipolar
disorder patients had varying degrees of
problems with short- and long-term memory,
speed of information processing, and mental
flexibility.
(Medications used for bipolar disorder, however,
could have been responsible for some of these
abnormalities and more research is needed to
confirm or refute these findings)
Seriousness of Disorder Cont.

 Substance Abuse
– Cigarette smoking is prevalent among bipolar
patients, particularly those who have frequent or
severe psychotic symptoms. Some experts
speculate that, as in schizophrenia, nicotine use
may be a form of self-medication because of its
specific effects on the brain.
– Up to 60% of patients with bipolar disorder abuse
other substances (most commonly alcohol,
followed by marijuana or cocaine) at some point
in the course of their illness.
Seriousness of Disorder Cont.

 Effect on Loved Ones

– It is very difficult for even the most loving families
and caregivers to be objective and consistently
sympathetic with an individual who periodically
and unexpectedly creates chaos around them.
– Often family members feel socially alienated by
the fact of having a relative with mental illness,
and they conceal this information from
acquaintances.
Seriousness of Disorder Cont.

 Economic Burden
– In 1991, the National Institute of Mental Health
estimated that the disorder cost the country $45
billion, including direct costs (patient care,
suicides, and institutionalization) and indirect
costs (lost productivity, and involvement of the
criminal justice system.)
– In one major survey, 13% of patients had no
insurance and 15% were unable to afford medical
treatment.
 Treatment of Bipolar Disorder
(a four phase process)

 Evaluation and diagnosis of presenting

symptoms
 Acute care and crisis stabilization for
psychosis or suicidal or homicidal ideas or
acts
 Movement toward full recovery from a
depressed or manic state
 Attainment and maintenance of euthymia
 This four phase process was according to (Himanshu P. Upadhyaya, MBBS, MS.,2002)
 Treatments

 Inpatient Care
 Assess the patient
 Diagnose the condition
 Ensure safety of patient and others
– This care is necessary for:
 Psychotic features

 Suicidal or homicidal ideations

 Treatments

 Antidepressant therapy
 Mood stabilizer
– Lithium carbonate
– Sodium divalproex
– Carbamazepine
 Antipsychotic Agents
– Risperidone
– Haloperidol
 Treatments

 Electroconvulsive therapy (ECT)

– Inpatient basis
– Severe cases
– Patient requires hospitalization often
 Faster than medications for therapeutic responses
 Memory loss before and after treatments
 3-8 sessions
 Medications are still required in maintenance phase of
treatment
 Mood Stabilizers
(Upadhyaya,2002)

Mood Stabilizer Common Adverse Doses Special Concerns

Effects
Lithium carbonate Lethargy or sedation, 300-600 PO tid/qid Hypothyroidism,
(Eskalith CR, tremor, enuresis, Must be adjusted by diabetes insipidus,
Lithobid) weight gain, overt monitoring serum polyuria, polydipsia
hypothroidism occurs level and patient
in 5-10% of patients response

Sodium divalproex/ Sedation, platelet 10-20 mg/kg/d Elevated liver

valproic acid dysfunction, liver Must be adjusted by enzymes or liver
(Depakote, disease, weight gain monitoring serum disease, bone
Depakene) levels marrow suppression

Carbamazepine Suppressed WBS, 200 mg PO bid Must Drug-Drug

(Tegretol) dizziness, be adjusted by interactions, bone
drowsiness, rashes, monitoring serum marrow suppression
liver toxicity(rarely) blood levels
 Mood Stabilizers Cont…

Gabapentin Headache, Not established Withdrawal

(Neurontin) fatigue, ataxia, seizures
dizziness,
sedation, weight
gain
Lamotrigine Sedation, Not established Stevens-
(Lamictal) dizziness, nausea Johnson
or emesis, diplopia, syndrome
ataxia, headache,
sleep disruption,
benign rash

Topiramate Nephrolithiasis, Not established Decrease doses

(Topamax) psychomotor in liver or renal
slowing, impairment
somnolence
 Mood Stabilizers Cont…

Felbamate Liver Disease, Not Aplastic

(Felbatol) photosensitivity Established anemia
, headache,
somnolence

Vigabatrin Weight gain, Not Unknown

(Sabril); agitation, Established
Investigational insomnia
drug
Psychotherapy

 Is not an effective treatment by itself, but can

be used in addition to medication
Types of therapy include:
-cognitive behavior therapy
-psychoeducation
-interpersonal therapy
-multifamily support groups
Cognitive Behavior Therapy

 More effective with the depressive part of

bipolar disorder
 “…Involves identifying irrational thought
patterns and altering [them] to better reflect
reality” ***Activities such as “daily mood logs”
can help (Wilkinson 2002)
Psychoeducation

 Learning signs and symptoms of his/her

disorder; what triggers mood alteration
 More useful for mania

---Being able to identify signs and symptoms of

mania is helpful in the prevention of a “full
blown manic episode” (Wilkinson 2002).
Interpersonal Therapy

 Helps to improve social skills and thereby

provides patients with more stability in
interacting with others
 Activities include:

- role playing
- modeling
- “guided in vivo practice” (Wilkinson 2002)
Multi-family Therapy

 Parent involvement in a child with BD by

teaching the child:
-relaxation techniques
-anger management
-decision-making skills
-communication/listening skills
-seeing that children don’t become “victims of
their illnesses” (Wilkinson 2002)
An Alternative Combination

 A combination of lithium and valproate can

be effective in treatment if monotherapy fails.
Treatment for Children and
Adolescents

 Lithium is one of the original treatments for bipolar

states in youth
 In a study in which chlorpramzine (thorazine) was
used, approximately 30% to 50% of youths had an
improvement with mood stabilizing
 In Frazier et al’s 2001 experiment, an eight week
study of using olanzapine monotherapy in 23
children and adolescents shown that there were
significant improvements of mania and depression
on doses ranging from 2.5 mg/day to 20 mg/day
Treatment Trends in the Elderly

 The number of new lithium users per year fell

from 653 to 281 in 2001 for older patients
 The number of divalproex users rose from
183 in 1993 to 1090 in 2001
 Though there has been a decline in elderly
lithium patients using lithium, lithium will
continue to be a mainstay until other mood
stabilizers are researched more extensively
Choosing the site of Treatment

According to the American Psychiatric Association, 2000:

 One of the first decisions the psychiatrist must make is the
overall level of care that the patient requires.
– Acute episodes of bipolar disorder are frequently of such
severity that patients require treatment in either a full or
partial hospital setting. (The least restrictive setting that is
likely to allow for safe and effective treatment should be
chosen.)
 If the patient is lacking the capacity to cooperate with treatment.
– Patients who are unable to care for themselves adequately,
cooperate with outpatient treatment of their mood disorder,
or provide reliable feedback to their psychiatrist regarding
their clinical status are candidates for full or partial
hospitalization, even in the absence of a tendency toward
intentional self-harm.
Site of Treatment Cont.

 If the patient is at risk for suicide or homicide

– Patients with suicidal or homicidal ideation require close
monitoring. Patients at high risk may benefit from
hospitalization, during with close observation, restricted
access to violent means and more intensive treatment are
possible.
 If the patient lacks psychosocial supports
– Recovery from acute bipolar episodes is aided by an
environment that encourages safety, constructive activity,
positive interpersonal interactions, and compliance with
treatment. If the home environment lacks these features or
exposes the patient to undesirable or dangerous activities,
such as alcohol or drug abuse, admission to a hospital or an
intensive day program may be necessary.
Works Cited

Bipolar Disorder. (2002). Well Connected A.D.A.M. Inc. Retrieved from www.well-connected .com .

Dinan, Timothy G. (2002, April 27). Lithium in bipolar mood disorder. British
Medical Journal, 324 (7344), 898-991.

Griswold, Kim S. (2000, September). Management of Bipolar Disorder. American Family Physician.
www.findarticles.com/cf_0/m3225/6_62/65286755/print.jhtml

Hirshfeld, R., Clayton, P.J., Cohen, I., Fawcett, J., Keck, P., McClellan, J., et al. (2000). Practice Guidelines for the
Treatment of Patients With Bipolar Disorder. American Psychiatric Association Practice Guidelines for the
Treatment of Psychiatric Disorders, Compendium 2000, 503-562.

Nathan, Peter F., Gorman, Jack M. (1998). A guide to treatments that work.
New York: Oxford University Press.

Schlozman, Steven C. (2002, November). The Shrink in the Classroom. An Explosive Debate: The Bipolar Child.
Association for Supervision and Curriculum Development. (89-90).

Shulman, Kenneth I. (2003, May 3). Changing prescription patters for lithium
and valproic acid in old age: Shifting practice without evidence. British Medical Journal, 326
(7396), 960-962.
Works Cited Cont.

Srinath, Rajeev J. et al. (2003, February). The Index Manic Episode in Juvenile-
Onset Bipolar Disorder: The Pattern of Recovery. Canadian Journal of
Psychiatry. Vol. 48 (1). Retrieved Oct. 22, 2003, from EBSCO Academic
Search Elite Database.

Sternstein, Aliya & Gross, Neil. (2002, August 12). Some uplifting news about
depression.
Business Week, (3795), 69.

Treatment. Journal of Mental Health Counseling, (24) 348+. Retrieved Oct 21,
2003, from EBSCO Academic Search Elite database.

Upadhyaya, Himanshu P. et al. (2002, October). Mood Disorder: Bipolar Disorder.

eMedicine. www.emedicine.com/ped/topic240.htm .

Wilkinson, Greta et al. (2002). Bipolar Disorder in Adolescence: Diagnosis and