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KEY CONCEPTS

KEY CONCEPTS

  • imageBipolar disorder is a cyclic mental illness with recurrent mood episodes that occur over a person’s lifetime. The symptoms, course, severity, and response to treatment differ among individuals.

  • imageBipolar disorder is likely caused by genetic factors, environmental triggers, and the dysregulation of neurotransmitters, neurohormones, and second messenger systems in the brain.

  • imageClinicians should obtain a detailed history, including medical history and substance use history, to expedite the diagnosis and treatment of bipolar disorder.

  • imageBipolar disorder is a complex psychiatric illness with significant morbidity and mortality. Suicidal thoughts and behaviors are common in individuals with bipolar disorder and need to be managed with medical and therapeutic interventions.

  • imageThe goal of therapy for bipolar disorder should be to improve an individual’s functioning by reducing mood episodes. This is accomplished by maximizing adherence to therapy and limiting medication adverse effects.

  • imagePatients and family members should be educated about bipolar disorder and treatments. Long-term monitoring and adherence to treatment are primary factors in achieving disease stabilization.

  • imageLithium, valproate, and second-generation antipsychotics are the mainstays of treatment for different phases of bipolar disorder, acting as primary mood stabilizers. When individuals with bipolar disorder present with an acute mood episode (eg, depressed episode, manic episode or mixed state) despite a primary mood stabilizer, adjunctive medications are considered to target the specific mood state or subtype. These medications can often be tapered once the acute episode has resolved and euthymia is reached. Baseline and follow-up laboratory tests are required for most medications used for bipolar disorder to monitor for adverse effects.

  • imageSome individuals can be stabilized on one mood stabilizer, but others may require combination therapies or adjunctive agents during an acute mood episode. Adjunctive agents should be tapered and discontinued when the acute mood episode remits and the patient is stabilized, if possible. These agents may include benzodiazepines, additional mood stabilizers, antipsychotics, and/or antidepressants.

PATIENT CARE PROCESS

Patient Care Process for Bipolar Disorder

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Collect

  • Patient characteristics (eg, age, race, sex, pregnancy status)

  • Patient psychiatric, medical, social, and family history

  • Current medications and prior medication use

  • Current and past sleep habits/patterns

  • Objective data

    • BP, heart rate, height, weight, and body mass index (BMI)

    • Laboratory test (eg, serum electrolytes, serum creatine [SCr], liver function tests [LFTs], thyroid stimulating hormone [TSH], urine drug screen [UDS])

    • Rating scale scores (eg, Young Mania Rating Scale [YMRS], Hamilton Depression Rating Scale (HDRS or HAM-D), Patient Helath Questionnaire 9 [PHQ-9])

Assess

  • Presence of hypomania, mania, or depression

  • Adherence to medication regimen

  • Appropriateness and effectiveness of current medication regimen

  • Serum concentration of medication if appropriate (eg, lithium)

  • Current medications that may contribute to or worsen mania or depression

  • Suicidality

  • Current sleep patterns

  • If no response to current medication regimen, reassess diagnosis

Plan*

  • If exhibiting euthymia, continue current regimen if appropriate

  • If exhibiting mania symptoms, immediately discontinue the antidepressant, optimize regimen, and consider the short-term use of benzodiazepine (see Table 89-4)

  • If exhibiting ...

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