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PATIENT CARE PROCESS

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Patient Care Process for the Management of Bipolar Disorder

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Collect

  • Patient characteristics (e.g., age, race, sex, pregnant)

  • 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 BMI

    • Laboratory test (e.g., serum electrolytes, Scr, LFTs, TSH)

    • Rating scale scores (YMRS, HAM-D, PHQ-9)

Assess

  • Presence of hypomania, mania or depression (see Table 69-2)

  • Adherence to medication regimen

  • Appropriateness and effectiveness of current medication regimen

  • Serum concentration of medication if appropriate (e.g., 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 euthymic, continue current regimen if appropriate

  • If manic, immediately discontinue antidepressant, optimize regimen, and consider short term use of benzodiazepine (see Table 69-5)

  • If depressed, optimize regimen and consider adding antipsychotic (i.e., quetiapine or lurasidone) (see Table 69-5)

  • Lifestyle modifications (e.g., nutrition, sleep, exercise, stress reduction)

  • Monitor for efficacy and safety of medications (see Table 69-7)

  • Treat comorbid psychiatric disease states

  • Patient education (e.g. purpose of treatment, lifestyle modification, drug therapy)

  • Self-monitoring for new mood episodes (daily mood chart) and sleep patterns

  • Referrals to other providers when appropriate (e.g., psychologist, psychiatrist)

Implement*

  • Provide patient education regarding all elements of treatment plan

  • Use motivational interviewing and coaching strategies to maximize adherence

  • Schedule follow-up

Follow-up: Monitor and Evaluate

  • Patient's psychiatric status (rating scale) and safety (suicidality)

  • Presence of adverse effects (e.g., weight gain, sedation)

  • Laboratory test (see Table 69-7)

  • Patient adherence to treatment plan using multiple sources of information and presence of residual symptoms

*Collaborate with patient, caregivers, and other health professionals

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CHAPTER SUMMARY FROM THE PHARMACOTHERAPY HANDBOOK

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For the chapter in the Wells Handbook, please go to Chapter 67. Bipolar Disorder.

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KEY CONCEPTS

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KEY CONCEPTS

  • Image not available. Bipolar 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.

  • Image not available. Bipolar disorder is likely caused by genetic factors, environmental triggers, and the dysregulation of neurotransmitters, neurohormones, and second messenger systems in the brain.

  • Image not available. Clinicians should obtain a detailed history, including potential substance use and medical illness, to avoid a delay in the diagnosis and treatment of bipolar disorder.

  • Image not available. The goal of therapy for bipolar disorder should be to improve patient functioning by reducing mood episodes. This is accomplished by maximizing adherence to therapy and limiting adverse effects.

  • Image not available. Patients and family members should be educated about bipolar disorder and treatments. Long-term monitoring and adherence to treatment are major factors in achieving stabilization of the disorder.

  • Image not available. Lithium and valproate are the mainstays of treatment for both acute mania and prophylaxis for recurrent manic and depressive episodes. Anticonvulsants (eg, lamotrigine, carbamazepine) and second-generation antipsychotics (eg, aripiprazole, quetiapine) are alternative or adjunctive treatments for bipolar disorder ...

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