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Outcomes
Mere decades ago, bipolar disorder, which is characterized by chronically occurring episodes of mania or hypomania alternating with depression, was considered an uncommon, even rare condition. Reasons why bipolar disease as a condition is often misdiagnosed will be discussed. The etiology, evaluation, prognosis, and management of this debilitating condition will be viewed, and the role of the various members of the health team will be considered. Treatment involving pharmacotherapy and psychosocial interventions will be discussed.
Objectives
At the completion of this course, the participant will be able to:
Recognize patterns of symptoms suggestive of bipolar disorder, its various subtypes, and related disorders.
Differentiate the diagnostic criteria for manic episodes, hypomanic episodes, and major depressive episodes.
Relate the epidemiology and diagnostic criteria of bipolar disorders.
Identify differential diagnoses for bipolar I disorder, bipolar II disorder, and cyclothymic disorder.
Summarize the proper pharmacologic and non-pharmacologic treatment for each type of mood disturbance seen in bipolar disorders.
CEUFast Inc. and the course planners for this educational activity do not have any relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.
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Bipolar disorder is all about mood shifts. Bipolar affective disorder, also known as bipolar disorder, is a brain disorder characterized by shifts in mood, energy, and functional ability. Bipolar disorder is an affective disorder. Affect means mood. Affect, along with cognition and conation, is one of the three core components of the mind. Affect represents an emotion, feeling, or emotional energy.
The presence of a mental disorder causing dysfunction in the effect, one of the core processes of our mind, shakes our ability to function to its very bedrock. Bipolar disorders, yes, there are more than one, lead to changes in mood, energy, and the ability to function. Those experiencing fluctuations in emotional state are hindered from proper function for days, weeks, or longer. The repetitive cycle of mood highs, alternating with deep depression, disrupts our behavior, choices, social interactions, daily routines, and even our desire to live.
Table 1: Terminology Moment
Affect is one of the three core components composing the mind. It consists of emotional energy and expression, both positive and negative.
Feelings
Emotions
Moods
Cognition is one of the three base structures of the mind. It refers to the process of coming to know and understand, the process of encoding, storing, processing, and retrieving information.
Knowledge
Understanding
Conation is one of three foundation components of the mind. It is the connection of knowledge and affect to behavior. It is the personal, intentional, planful, deliberate, purposeful, or striving component of motivation, the initiative-taking (as opposed to reactive or habitual) aspect of behavior.
Bipolar disorder is one of the top ten causes of disability worldwide(Jain & Mitra, 2023). It runs in families; 80 to 90 percent of those diagnosed with bipolar disorder have at least one blood relative with an affective disorder such as bipolar, mania, or depression (American Psychiatric Association [APA], n.d.). Occurrence runs neck and neck in both sexes, with 2.8% of Americans of both sexes predicted to have a new initial manifestation of bipolar symptoms each year. While bipolar disorder can manifest at any age, it is mostly seen in those 18 years of age and older, with the average age of onset being 25 years old. To put it in a distinct perspective, around 4.4% of American adults will experience, at some time in their lives, the turmoil of bipolar disorder (Ichhori Team, 2023).
Worldwide, bipolar disorder is regarded as a common disorder. Around 1% of the global population experiences bipolar I, with another 1.5% having bipolar II (Rubin, 2023), with no real difference regarding culture or race. Please note that actual numbers are much higher due to the difficulties in achieving an accurate diagnosis, which often requires sufficient time spans for client observation. Those with bipolar disorder of any type suffer an estimated ten-year loss in the length of life, with death by suicide being a frequent outcome.
Affective disorders, or mood disorders as they are often referred to, are common psychiatric disorders that lead to significant life-impairing suffering. In the APA Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5), the go-to for recognizing and treating mind and brain troubles, affective disorders fall into the categories of bipolar and depressive disorders (APA, 2022).
Caution, honesty ahead. No one can provide clinical proof of what causes bipolar disorder. What is known, such as the frequency of blood relatives with significant affective disorders, is even more important until we know more. The presence of a significant, strong life event, usually traumatic, seems to proceed with the onset of observable bipolar symptoms. At least 60% of clients with diagnosed bipolar disorder have had one or more major stress-filled life events in the six months prior to diagnosis (Jain & Mitra, 2023).
The current assumption is that chemical imbalances of monoaminergic neurotransmitters, especially serotonin and dopamine, interfere with the intercellular regulation of emotions and mood (Jain & Mitra, 2023). It is a solid theory. However, no single neurohormonal dysfunction has yet been directly/repetitively linked to the crippling effects of bipolar mood dysregulation.
Moods and emotions are essential to how our mind works. The swinging of the internal energy we call moods beyond our normal, or euthymic even keel of daily living is at its extreme, bipolar disorder. Bipolar disorder, or double trouble as some of our client groups prefer, is the swinging of internal emotional energies from a well-regulated normal to pressured highs alternating with depressive lows.
Mania or manic episodes (a component of bipolar disorder) are composed of extreme highs of internal energies. Energies that intrude and make shambles of a well-regulated life. Indicators of mania include (BetterHelp, 2024a; Leonard, 2023):
Feelings of euphoria.
High energy levels with periods of overactivity.
Sleep troubles with feelings of lessened need for sleep.
Hypomania is excited internal energies such as in mania, yet in a slightly less intense state. Interestingly, hypomania is mostly seen by friends, family, and peers rather than by the clients themselves. These intense energies are disruptive to a structured, well-focused life.
Euthymia is the gold standard of well-being. This term, sadly underrepresented, means living life feeling emotionally well, happy, and content (Black, 2023). Having mild yet short-lived difficulties returning quickly to that stable, functional baseline of mood is known as euthymic. Those with bipolar disorder do return to their normal euthymic baseline, sometimes for prolonged periods, months, or years, or sometimes just for a brief period while on their way to another extreme of mood. As health professionals, we strive to help our clients return to a euthymic life, a sense of normality, and good emotional function.
Depression is sometimes referred to as an emotional pit—a gloom of lowered internal energies and hopeless sadness that seems forlorn and escape-proof. Depression is the low swing of the pendulum we call bipolar disorder. On average, more time is spent in depression than in mania or hypomania, with depressive episodes accounting for 75% of all dysthymic time (Rubin, 2023). Indicators of depression below the occasional bad, sad day include:
Feelings of hopelessness or sadness.
Low energy or unusual fatigue.
Sleep disturbances that are unusual for the client ranging from oversleeping to insomnia.
Lowered self-esteem and feelings of self-worthlessness.
Loss of concentration and ability to problem solve.
Anhedonia, which means loss of interest in things once enjoyed.
Aches and pains appearing without an obvious cause.
Indicators that may be shared in bipolar disorder by both the emotional highs, mania, and hypomania, and the dark mood lows, depression, include (Leonard, 2023):
Bipolar affective disorder comes in four or seven types, depending on how the pie chart is sliced. The confusion is that symptomologies sometimes overlap, which has led to frequent diagnostic difficulties in the past. Three major categories of bipolar are generally agreed on amongst professionals, with the "fourth" category being broken down by the DSM-5 Text Revision into four further categories, making a total of seven forms of bipolar disorder.
This is what most think of when they hear bipolar. It involves both mania and depression, with episodes of visible, severe mania lasting for one week or more. Depressive episodes may also be present, not at the same time as mania, in a deep interfering with life functions depression, referred to as major depression. Depressive episodes, when present, tend to last for two weeks or longer. Please note that observed depressive events are not needed to warrant a diagnosis of bipolar I.
Table 2: DSM-5 Bipolar Disorder I Diagnostic Criteria
Criteria must be met for at least one manic episode, which might have been preceded or followed by a hypomanic episode or major depressive episode (hypomanic or major depressive episodes are not required for the diagnosis).
A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goal-directed activity or energy, lasting at least one week and present most of the day, nearly every day (or any duration if hospitalization is necessary).
During the period of mood disturbance and increased energy or activity, three (or more) of the following symptoms (four if the mood is only irritable) are present to a significant degree and represent a noticeable change from usual behavior:
Inflated self-esteem or grandiosity.
Decreased need for sleep (e.g., feeling rested after only three hours of sleep).
Being more talkative than usual.
Flight of ideas or the subjective experience of racing thoughts.
Distractibility (i.e., attention too quickly drawn to unimportant or irrelevant external stimuli), as reported or observed.
An increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation (i.e., purposeless non-goal-directed activity).
Excessive involvement in activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or risky business investments).
People experiencing severe mania may also experience significant delusions, psychosis, or paranoia, which are not present in hypomania.
The mood disturbance is sufficiently severe to cause marked impairment in social or occupational functioning or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features present.
The episode is not attributable to the physiologic effects of a treatment or medication, including cases of substance abuse.
In bipolar II, the focus switches to the shifting in and out of depressive episodes. Significant life-impairing depression with a history of at least one episode of hypomania that lasted at least four days classifies bipolar II disorder. It can either proceed a known episode of hypomania or follow it.
Table 3: DSM-5 Bipolar Disorder II Diagnostic Criteria
Criteria must be met for at least one hypomanic episode and a major depressive episode. These can occur at any point over the course of a lifetime.
Hypomania requires at least four days of elevated mood change, which might include feelings of increased energy, irritability, and expansiveness. You must have at least three of the following symptoms during this time. If your mood has been (or is normally) exclusively irritable, you must have four of the following symptoms.
Exaggerated sense of well-being and self-confidence (euphoria), grandiosity.
Decreased need for sleep.
Unusual talkativeness.
Rushed or scattered thinking, racing thoughts.
Attention/focus issues, distractibility.
Psychomotor agitation is an increase in purposeless physical activity (e.g., restlessness, pacing, tapping fingers or feet, abruptly starting and stopping tasks, rapidly talking, and moving items around without meaning) or an increase in "activity toward goals."
Impulsivity, poor decision-making, and risk-taking.
For a bipolar II diagnosis, a major depressive episode requires at least 14 days duration and the presence of at least four of the following.
Significant changes in weight and/or appetite.
Sleep disturbance, too much (hypersomnia) or too little (insomnia).
Cyclothymic disorder (bipolar III), also known as cyclothymia, is made up of frequent episodes of depressive and hypomanic behaviors. What sets this apart from bipolar I (mostly manic) and bipolar II (mostly depressed) is that the emotional highs and lows, though frequent, are not as intense as those found in bipolar I or II.
For diagnosis, symptoms of hypomania or depression must be observable in the client at least half of the time over a period of at least two years. Euthymic, symptom-free periods may not last for more than two consecutive months during the diagnostic interval (Gurarie, 2024).
Table 4: Rapid Cycling in Bipolar Disorders
Rapid cycling is a feature that may be found in any type of bipolar disorder and is not a separate diagnosis. A client can be said to have bipolar disorder with rapid cycling when they experience at least four distinct abnormal mood episodes over a 12-month period. Rapid cycle episodes tend to appear unexpectedly and are mostly transient.
At some point in their lives, 26% to 43% of those diagnosed with bipolar disorder of any type will experience at least one period of rapid cycling.
(Lovering, 2022)
To solidify the diagnosis, there can be no client history of mania, hypomania (separate from the cycling indicative of bipolar), or straight depression (APA, 2022). Other conditions or disorders that might mimic cyclothymia must also, of course, be absent.
Table 5: Psychosis in Bipolar Disorders
During extreme affective episodes, either depressive or manic, a client may experience sensations, sounds, and visions that are not reality-based yet seem very real to that person.
Research shows that 50% or more of those diagnosed with bipolar will experience symptoms of psychosis at some point.
Psychosis may include delusions, hallucinations, or both.
Delusions are composed of unshakable certainty that something is true despite evidence showing it to be false.
Hallucinations are sensations where a person sees, hears, and smells things that are not present.
The DSM-5, from the APA, has taken the old-school bipolar IV, "Other," and divided it into four categories, making the new number of bipolar and related disorders total seven.
Diagnosis of this type of bipolar involves a substance such as alcohol, illicit drugs, prescribed medication, heavy metals, or toxins (PsychDB Staff, 2022). The presence of manic/hypomanic and/or depressive symptoms occurs either while the person is using the substance or during a withdrawal syndrome associated with the substance. Changes in mood must be both prominent and persistent.
Discernment is needed to distinguish this diagnosis from other substance use conditions. Of note, differentiation of the observed symptoms of bipolar disorder from substance-induced delirium must occur (Huizen, 2022).
Diagnosis of this type of bipolar disorder occurs when there is a prominent and persistent period of abnormally elevated, expansive, or irritable mood along with abnormally increased activity or energy that is attributable to another medical condition. Medical conditions commonly associated with bipolar mania or hypomania include (AbbVie Medical Affairs, n.d.):
Cushing's disease.
Brain injuries.
Stroke.
Primary psychogenic polydipsia with associated hyponatremia.
The DSM-5 utilizes the diagnostic classifier Other Specified. When you see it, be aware that it represents, in general, that presenting symptoms almost, yet not quite, meet what is needed for the diagnosis to which it is attached. In this instance, the other specified precursor represents that this individual likely presents with episodes of observable mania/hypomania and/or visible depression yet does not completely meet the criteria for a diagnosis of the specific form of bipolar that they would otherwise warrant (French, 2023).
Bipolar disorder unspecified is, in many ways, a placeholder. When it looks like a duck, sounds like a duck, yet more information is needed (such as a good history, which is very important in diagnosing bipolar), the diagnosis "Unspecified" is available (NeuroLaunch, 2023b).
Unspecified bipolar disorder represents a client who has the symptoms of bipolar disorder yet, for whatever reason, cannot be categorized into a more specific bipolar affective disorder(McKechnie, 2023).
Table 6: Case Study 1
Marcel felt grumpy. Weekend coverage as a resident psych intern was the lowest point of her month. Take this overnight case brought in by the police and dropped off with a cheery "your problem now" by the escort officer.
Varel, a 23-year-old mixed-race female, was arrested at closing time in a high-income clothing boutique after racing around the store clad only in expensive designer undergarments shouting, "Look at me now" and "Easter is here, the bunnies told me so." The police report dropped off with the client indicates Varel had spent the preceding afternoon in the uptown shopping district on a wild shopping spree, paying with credit. Shop owners reported high energy, pressured speech, and excessive spending.
In-person, an interview with Varel revealed a coherent, though pressured, and easily distracted historian. Varel reported not sleeping for the last several days, except for short naps. She also frequently stated that she was in her happy mode, much better than when the darkness demons visited. She also related openly that objects and animals sometimes spoke to her- pleasant words during her happy times and accusing bitter things during her dark periods, telling her she needed to kill herself.
Marcel sighed as she began her dictation—manic, manic, manic, with what sounded like periods of depression. Bipolar disorder, yet wait, she really needed a family member or friend to give input on the frequency and duration of the dysfunctional mood episodes and laboratory essays to rule out metabolic disorders such as thyroid disorders. Hmm, that meant a working diagnosis.
(Unspecified Bipolar Disorder with Psychotic Features)
The DSM-5 includes ten different specifiers that clinicians can append to the bipolar diagnosis to include more information about the current or most recent mood episode (APA, 2022).
Anxious distress: Used to describe the most recent mood episode if it can be characterized by feeling keyed up, tense, restless, difficulty concentrating due to worry, fear of impending doom, and feeling like the individual might lose control of themselves.
Mixed features: If the most recent mood episode was either manic or hypomanic, this specifier is used to describe prominent dysphoria, depressed mood, tearfulness, fatigue, loss of energy, excessive guilt, feelings of worthlessness, suicidal ideation, psychomotor retardation, and anhedonia. Suppose the most recent mood episode was major depression. In that case, this specifier is used to describe an elevated, expansive mood, grandiosity, pressured speech, flight of ideas, increased goal-directed activity, and decreased need for sleep.
Rapid cycling: A specifier describing at least four mood episodes in the last 12 months.
Melancholic features: Used to describe a loss of pleasure in activities, lack of reactivity to pleasurable stimuli, depressed mood in the morning, moroseness, profound despondency, early-morning waking, excessive guilt, weight loss, or psychomotor agitation.
Atypical features: This specifier can be used to qualify a major depressive episode with predominantly atypical symptoms such as mood reactivity, weight gain, increased appetite, hypersomnia, leaden paralysis, and interpersonal rejection sensitivity.
Psychotic features: The presence of delusions or hallucinations during mood episodes.
Mood-congruent psychotic features: Psychotic symptoms that mimic the typical themes of a mood episode. For example, mood-congruent psychotic symptoms during a manic episode would include themes of grandiosity, invincibility, and suspiciousness.
Mood-incongruent psychotic features: The presence of psychotic symptoms that are unrelated to typical themes related to the current mood episode.
Catatonia: Used to describe a manic or depressive episode with prominent catatonic features.
Peripartum onset: Used to describe the onset of a mood episode either during pregnancy or within four weeks after delivery.
Seasonal pattern: This specifier is used when the patient experiences a regular seasonal pattern of mood episodes.
Those who have bipolar disorder are at an increased risk of committing suicide. Recent literature reveals that 34% of those with bipolar disorder will attempt suicide, with 15% of disorder sufferers completing suicide(Rubin, 2023). To help put this into perspective, more clients experiencing bipolar symptoms attempt suicide than in any other psychiatric diagnosis, including unipolar depression.
The emotional roller coaster of bipolar disorder places clients at a heightened risk for suicide, not only during depressed episodes but also during manic swings when the executive decision-making process and the ability to make a good judgment are impaired. While suicide is a major risk for all bipolar clients, certain factors tend to affect the potential for suicidal thoughts or acts. Early diagnosis and treatment decrease a client's risk of suicide; however, the following factors increase the risk of suicide or self-injurious behavior.
Personal or family history of suicidal behavior.
Severity and number of depressive episodes.
Alcohol or substance dependency.
Heightened degree of pessimism.
Level of impulsivity or aggression.
Younger age of symptom onset.
Table 7: Case Study 2
Geraldo is a 29-year-old Hispanic male admitted after being found unconscious in a parked car outside of his ex-spouse's apartment complex. Empty prescription medication containers were found in the passenger seat next to him by the deputy sheriff, who had been called to investigate a suspicious vehicle. The medications involved are:
Paroxetine is a serotonin reuptake inhibitor (SSRI) antidepressant.
Methylphenidate hydrochloride is a mild central nervous system (CNS) stimulant.
Modafinil is a medication used to combat sleep disorder.
Also found with Geraldo was a small spiral-bound notebook of the type commonly issued during counseling for journaling thoughts and feelings. The handwriting on the last few pages of the notebook is difficult to decipher, yet it mentions the loss of friends, spouse, and job due to recurrent bouts of major depression. No suicide note is present.
Geraldo's former wife reports that she has been without contact with him for several months; however, she recently heard from former friends that he was without a job or a place to live. She reports Geraldo has a longstanding history of "laziness," where he would just lay around the house without bathing or even talking to her, and that he put little effort into relationships or maintaining employment.
Geraldo's former wife also reports that his underlying inattentiveness was interrupted by occasional periods of high energy that lasted a few weeks but occurred infrequently. She further reports that she had pressed Geraldo to seek treatment for depression after losing several jobs. However, even after treatment for major depression, nothing seemed to change, so she decided that the lack of interest he showed in their relationship and in seeking work must be his choice.
She adds that she hopes he will wake up and grow out of it someday.
Bipolar disorder is commonly mistaken for major depressive disorder; treatment, however, differs.
Bipolar disorder is frequently misdiagnosed as something else, even now with our current understanding of the condition.One study reports up to 40% of those with bipolar disorder, as many as 8 million people worldwide, receive a wrong diagnosis of something else, most commonly, it seems, major depressive disorder(Pedersen, 2022). Once a misdiagnosis is made, clients can go as long as ten years, according to one source, before a correction to their diagnosis and treatment is made (Tracy, 2022).
The basic dichotomy of bipolar, with its highs and lows, leads to incorrect interpretations as to what is going on. Even among professionals, what you see now has more impact than a client's perhaps vague psychosocial history. What is seen now means more than historical words.
This has been one root problem with past bipolar flubs. If the client looks depressed, they have depression. If they have manic behaviors, it is an anxiety or hyperactive disorder. The focus on a good client history has fortunately been an important emphasis over the past few years; this has been a real boon toward greater accuracy in client care.
Symptoms from other medical and mental conditions can present as symptoms of bipolar disorder. Some of the more common include (Farnsworth, 2023; Tracy, 2022):
There are no blood, imaging, or verbal questionaries that can give an accurate positive diagnosis for bipolar disorder. Be aware a complete laboratory panel is still necessary to rule out medical or substance use conditions that might mimic bipolar disorder (Soreff, 2022).
Screening for bipolar disorder is not simple. The blur into major depressive disorder is huge, as most of the swing time in bipolar disorder is spent in the realm of deep depression. When mania or hypomania is present, the easy diagnosis is that of substance use or metabolic imbalance, not a major mood disorder. Laboratory profiles are important to rule out specific items, yet client history and screening tool application form the basis for good clinical diagnosis.
There are a few semi-structured interview tools available that have been found helpful for the diagnosis of bipolar disorder. The two most used of these are the Structured Clinical Interview for DSM, or SCID, and the Schedule for Affective Disorders, or SADS(BetterHelp Editorial Team, 2024b). SCID is often used during clinical interview situations. Both tools provide interview probes for symptom exploration and lead to exclusion criteria.
One of the popular bipolar-related brief evaluation tools is the Mood Disorder Questionnaire (MDQ), which focuses on determining symptom severity. For those curious, the website Mental Health America has a free online bipolar test based on the Mood Disorder Questionnaire (BetterHelp Editorial Team, 2024c). Another often-used questionnaire is the General Behavior Inventory, which has a consistent sensitivity of .75 with a specificity greater than .97. However, be cautious when handling this without guidance as some of the phrasing may be difficult for lay persons to understand.
The Rapid Mood Screener (RMS) is a brief, less than two-minute, self-administered tool focused on exposing bipolar I to major depressive symptoms. Although a recent tool, results are demonstrating good clinical worth (Thase et al., 2023).
The Young Mania Rating Scale (YMRS) and the Bech-Rafaelsen Mania Rating Scale (MRS) are widely used for measuring mania symptoms. They are of immense help in documenting progress when given at the beginning of treatment and periodically throughout.
The Goldberg test assesses both depression and mania symptoms. It is a self-administered, 18-question, 15-minute questionnaire specific to symptoms of bipolar disorder (NeuroLaunch, 2023a).
Bipolar disorder is a complex, frequently lifelong condition requiring a strategic plan of treatment best served with a combination of medications, therapy sessions, and a good personal life structure. Medications give the best result in a combination of mood-stabilizing agents, antipsychotics, and antidepressants or benzodiazepines, depending on which mood is predominant (Pope, 2024).
Psychopharmaceuticals are the initial and primary line of approach for controlling the extreme swings of emotions that accompany bipolar disorder. Four key observations control which medication is chosen and include the following (Jose, 2023):
The presenting symptoms at the time of diagnosis.
Effectiveness of a medication.
How the client tolerates this medication and its unwanted effects.
Is this medication safe for this client?
Be aware that all pharmaceuticals have adverse effects, and many of the medications used in bipolar disorder treatment require close monitoring and, for some, regular blood levels.
The primary medication class for control of bipolar disorder is drugs that diminish the quickness and extent of emotional swing away from euthymia, which are primary mood stabilizers and certain anticonvulsants. In general, this type of medication works directly in the brain, diminishing the ability of certain cells in the brain to become over-excited.
The mineral lithium is a mood stabilizer and one of the oldest medications still in active use for the treatment of bipolar mood swings. Lithium acts by influencing the flow of sodium throughout the brain and body in nerve and muscle cells (Thornton, 2023). Sodium contributes metabolically to excitation or mania.
Lithium is the best-known mood stabilizer, known for its ability to help regulate bipolar mania. It may also help control bipolar depression. It is not, however, as useful for rapid cycling bipolar or mixed mood episodes. Sadly, lithium has lost its popularity over the last decade despite being acknowledged as the most efficacious and cost-friendly treatment yet utilized for bipolar disorder (Kessing, 2024). In fact, according to the International Journal of Bipolar Disorders, while only 35% of bipolar clients worldwide currently utilize lithium, 70% of those with bipolar would be positively affected by its use (Kessing, 2024).
Several anti-seizure medications have been found beneficial in stabilizing moods. Perhaps the most prescribed of these is Depakote, sometimes referred to as valproic acid. The antidepressant Depakote is what is referred to as a prodrug. No, please do not look for professional sportswear for team Depakote; what prodrug means in this context is that once ingested, divalproex sodium transforms into another metabolically active form, valproate (Reale, 2023). Valproate aids in regulating levels of the amino acid gamma-aminobutyric acid (GABA) in the brain. GABA, in turn, regulates or modulates nerve cell activity, reducing excessive activity.
Divalproex is available in many forms, only one of which is officially approved for the treatment of bipolar disorder mixed/manic episodes. Uses include bipolar mania, bipolar depression, treatment of impulsivity, agitation, and aggression (Reale, 2023).
Valproic acid is primarily an anti-seizure medication and, as an adjunct, is used to boost the effects of another primary seizure control medication. It has some use in the control of the manic side of bipolar disorder. It is thought that the primary mode of action is blocking sodium uptake into neurons, thus slowing excitatory response (Rahman et al., 2023).
Lamictal is another anticonvulsant medication used as a mood stabilizer by stabilizing abnormal electrical activity in the brain. Lamictal has been approved by the U.S. Food and Drug Administration (FDA) for use with bipolar type I.
Carbamazepine is another anti-seizure medication found useful in dampening mood swings. It reduces the excitability of nerve cells in the brain and effectively reduces mania and, to a lesser degree, depression. It does tend to cause anemia, so routine drug levels and blood counts will be needed.
Each mood stabilizer and anti-seizure medication will have its own profile of potential adverse actions. In general, as a group, a 2023 overview of mood stabilizers lists the following as potential unwanted effects (Moore, 2023):
Nausea or vomiting.
Diarrhea.
Low sodium.
Dizziness.
Tremors.
Headache.
Blurry vision or vision changes, such as seeing two images.
Medications termed antipsychotics are primarily used to treat schizophrenia and other psychotic disorders. Some, however, have been shown to help with the management and secondary symptoms of bipolar. They are used in conjunction with a mood stabilizer. We will take a brief look at the most employed for the treatment and maintenance of a bipolar client.
Olanzapine is a second-generation antipsychotic used in the treatment of psychotic symptoms (hallucinations, delusions) in adults and children aged 13 or older. It has shown use in bipolar I and has even been marketed as a combination medication named Symbyax with fluoxetine (an antidepressant), specifically targeted toward the treatment of depressive episodes in bipolar type I (Nguyen, 2023).
This is another second-generation antipsychotic used in bipolar manic and mixed episodes. It can be used alone, yet generally, it is employed with a mood stabilizer. Aripiprazole finds frequent use for long-term maintenance in bipolar disorders.
Lurasidone is an atypical antipsychotic whose ability to alter brain chemistry aids in controlling bipolar depression.
Antipsychotic medications can cause unwanted effects. Each medication has its own specifics. As a drug class, in general, side effects may include (Smith, 2022):
What? You are no doubt thinking. The past consensus has been to just say no to the use of antidepressants with any type of bipolar disorder. Hear me out, however. Antidepressants pose a real risk for prompting or exacerbating manic episodes. However, some psychiatrists have found benefits in using an antidepressant as an adjunct to a mood stabilizer (Jose, 2023). Be aware antidepressants are not indicated as a stand-alone therapy for bipolar disorder, and many misdiagnosed bipolar clients are treated as though they have major depression—the wrong treatment, unfortunately, for our patients with bipolar disorder. Suicidal thinking is a risk both in untreated bipolar and with the use of antidepressants. Hence, the black box warning on antidepressants.
Be it to control anxiety in mania or get a handle on overwhelming fear and terror during the depth of the depression, and antianxiety medication has a place in the toolbox clinicians use for the treatment of bipolar disorder.
Benzodiazepines form the backbone of antianxiety treatment. Medications such as clonazepam, lorazepam, or oxazepam have all found use with bipolar clients in acute settings. Antianxiety medication use should be limited to acute settings while waiting for the mood stabilizer regime to kick in due to the potential for substance use disorder to develop (Smith, 2024).
Talk therapies, as psychotherapies are often referred to, are just as important, according to some professionals, in managing a client's bipolar condition as long-term maintenance medications. The point is, controversy aside, the bipolar client should always be referred to follow-up with some sort of talk therapy once initial symptoms are stabilized. The best form of psychotherapy is one that fits an individual client's needs and personality. Fortunately, there is an assortment to choose from.
CBT is a commonly available form of psychotherapy. Many practitioners consider CBT to be the most effective talk therapy for bipolar. The intent is to lead clients to be more in tune with their thoughts, particularly how they influence emotions and behavior. Of significant importance is the identification of triggers for a bipolar episode with an emphasis on the development of healthy strategies for managing both stress and other bipolar symptoms.
IPSRT is a common and helpful therapy involving awareness. Some of us would regard it as a journaling nightmare. However, it is helpful for a segment of the bipolar population, contributing to feelings of being grounded and in control of their lives. It consists of assisting clients with log information about their daily activities. Data logs may include such things as wake-up times, bedtimes, times of any nighttime wake-ups, mealtimes and what was eaten, exercise times, activities with their times, and short details should be included, as well as time spent in each day's life functions. With the guidance of a therapist, clients begin to be able to examine their lives and plan good life choices.
Entire families are impacted by bipolar disorder in a family member. FFT includes the client and their entire family unit. Elements of psychosocial education, bipolar-specific teaching, recognizing early signs of transition into a new episode, ways to minimize symptoms, and ways to decrease the time spent in a mood episode are covered. As a bonus, conflict management and communication skills are emphasized.
Unfortunately, a pill a day does not control or remit bipolar symptoms. It is going to take work and commitment from the affected client and their support network. Management strategies and tools are essential. Do not despair; studies and real-life experiences from other professionals have shown that self-care and self-awareness will help bipolar clients maintain that balanced euthymic goal so sought after.
Education on what is normal and what is the result of emotions altered by the disease process is often the starting point of therapy, even as the first medications are issued for acute symptoms. Nicely done! That is a great start; now build on it. Education and explanation should continue throughout the lengthy, at times lifelong, disease process (Vieta & Colom, 2024). One of the aspects covered in this type of disease-specific psychoeducation is how to anticipate and be initiative-taking in managing mood episodes. Another is sharing what type of tools, be they medications, talk therapies, or alternate options, are available so the client can make informed selections on what might work best for them.
"I can't sleep; I feel a manic episode coming on. It's time for my action plan!" Ah, how health professionals dealing with bipolar clients dream that this sort of dialogue would take place. However, we just need to coach and help our clients plan and form what they want to happen when they see/feel the precursors of an emotional episode. So, help your client and their support people think through and put in writing plans for swinging into mania and sliding into depression. Practice the plans repeatedly before they are needed (Geng, 2023). Plan information may include:
Which health professionals to call, along with contact information.
How to reach key support friends and family.
Written, easy-to-find phone numbers and contact details.
Written, easy-to-find medication and diagnosis details.
Contact information for a local mental health crisis center and specific names of workers they have already contacted.
Locations of nearby walk-in crisis centers and emergency rooms, along with taxi contact numbers and cash set aside for the ride.
Number for the National Suicide Prevention Lifeline: Call or text 988.
One of the great tolls bipolar disorder takes on those who live with it is disruption; some clients would say the destruction of any semblance of a structured, "normal" lifestyle. This may be one of the factors that result in bipolar client's mortality coming ten or more years sooner than expected (ScienceDaily, 2024).
Lifestyle therapy consists of practical steps toward creating a structured, simple daily script with easy-to-follow, healthy, pre-planned activities. As many of us have seen with our bipolar clients, being in a structured environment is a true relief to our mood swing clients. Let us help them take the structure from the hospital or clinic and put it into their daily lives. With a healthy lifestyle, we may be able to give them back ten years of a quality life.
The benefit of a brief electrical current to the brain, typically while under a light anesthesia or muscle relaxant, has been well documented as treatment for severe depression or bipolar disorder. When medications and therapies have proven unhelpful or of little assistance, and the symptoms remain egregious, a shock to the system, in this case, the cerebrum, helps in over 80% of cases. The prevalent theory is that the electrical current, which mimics a light seizure, redistributes neurotransmitters and stimulates neuroplastic changes in the brain. ECT has been shown to help stabilize mood, reducing both manic and depressive episodes in bipolar (Pedersen, 2023).
The sense of control and empowerment, according to bpHope magazine (Kildare, 2023), are just a sample of the benefits bipolar clients achieve when introduced to routine exercise therapy. Something achievable, with palpable results, allows clients to provide stability and a ready outlet for emotional tensions. Brain neurotransmitters function better when moderate exercise routines designed specifically for individuals are implemented and encouraged.
Resist snorting. Modern health care sorely lacks nutrition support for specific disease processes. It is true that some things considered dietary have shown to be helpful for those suffering from this brain disorder. A good diet and nutritional supplements do not replace medication or talk therapies. They support and encourage the body/brain metabolism, bringing better function. The following have been shown as promising complementary supports in treating bipolar (Felman, 2023):
Omega-3 fatty acids- small studies have shown a reduction of both depressive and mania symptoms.
Thiamine- shows a beneficial effect on anxiety.
Folate- shows a favorable effect, in conjunction with regular medication therapy, in lowering both mania and depression in bipolar disorder.
Tryptophan- shows benefits in lowering anxiety and improving mood, though no dedicated studies directly related to bipolar disorder have been cited.
CoQ10- shows a decrease in depressive symptoms during the depression phase of bipolar disorder.
L-tyrosine- shown to have protective effects for memory issues during periods of stress and a degree of protection from cognitive issues.
The use of magnetic wave stimulation on the brain has shown promise for depressive symptoms. A meta-analysis has shown that magnetic wave therapies benefit those with major depression and have a lesser, though still present, benefit on clients with bipolar disorder in the depressive phase of their disorder (Kishi et al., 2023). The result of this meta-analysis might be summed up as, and yes, I am paraphrasing, it does not hurt to try, especially if current treatments are proving inadequate on their own.
Peer support is important for all clients suffering from a brain disorder, and bipolar suffers truly benefit. Those with bipolar are often associated with behaviors leading to a social stigma. In addition, bipolar clients often express that no one understands them and what they are going through. Peer groups help resolve this isolation, and clients can benefit from strategies that have worked for others in similar circumstances, such as being in a group where they are understood and accepted. Groups are not a substitute for individual therapy or counseling. Several online bipolar peer support groups have grown up. This is an option for certain situations. However, face-to-face support is still preferred when available.
Bipolar affective disorders are disorders of the brain that may last a lifetime, bringing episodes of deeply depressive emotional lows interspaced with hyper-energetic mood highs. Many afflicted by this brain disease contemplate, attempt, and succeed at suicide as a means of coping with the intense turmoil bipolar episodes create in their lives.
More people have bipolar disorder than are currently diagnosed. The spectrum of illness created by bipolar swings can vary widely yet share the characteristics of significant shifts in mood and inability to function effectively in life. Often, bipolar disorder is misdiagnosed and mistreated. Effective treatment consists of medication, psychotherapy, and ongoing support to minimize the aversive effects of bipolar symptoms while keeping this ever-present disorder in remission.
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Implicit Bias Statement
CEUFast, Inc. is committed to furthering diversity, equity, and inclusion (DEI). While reflecting on this course content, CEUFast, Inc. would like you to consider your individual perspective and question your own biases. Remember, implicit bias is a form of bias that impacts our practice as healthcare professionals. Implicit bias occurs when we have automatic prejudices, judgments, and/or a general attitude towards a person or a group of people based on associated stereotypes we have formed over time. These automatic thoughts occur without our conscious knowledge and without our intentional desire to discriminate. The concern with implicit bias is that this can impact our actions and decisions with our workplace leadership, colleagues, and even our patients. While it is our universal goal to treat everyone equally, our implicit biases can influence our interactions, assessments, communication, prioritization, and decision-making concerning patients, which can ultimately adversely impact health outcomes. It is important to keep this in mind in order to intentionally work to self-identify our own risk areas where our implicit biases might influence our behaviors. Together, we can cease perpetuating stereotypes and remind each other to remain mindful to help avoid reacting according to biases that are contrary to our conscious beliefs and values.
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