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					Treatment
Treatment Overview
   Treatment depends on phase of illness and severity of
    symptoms
       Acute Phase: Aimed at ending current manic,
        hypomanic, depressive, or mixed episode
       Preventive and Maintenance Phase: Continued on a
        long-term basis to prevent future episodes
   Treatment Modalities
       Medication: necessary for nearly all patients during
        acute and preventive phases
       Education: crucial in helping patients and families learn
        how best to manage bipolar disorder and prevent its
        complications
       Psychotherapy: helps patients and families affected by
        bipolar disorder deal with disturbing thoughts, feelings,
        and behaviors in a constructive manner
        (Healthy Place, 2008)
Pharmacological Treatment of
Depressive Episodes
Antidepressants                       Used as adjunct to mood
   Tricyclic Antidepressants          stabilizing drugs
   Monoamine Oxidase Inhibitor           If used alone, antidepressants
    (MAOI)                                 can sometimes cause
                                           "switching" into mania
   Selective Serotonin Reuptake
    Inhibitor (SSRI)                       (Geitner, 2008)
      Escitalopram (Lexapro),
        Flouxetine (Prozac)           Drug choice may be based
   Serotonin Norepinephrine           on patient symptoms
    Reuptake Inhibitor (SNRI)             Anxious patient may receive
                                           drug with greater sedative
      Venlafaxine (Effexor),
                                           effect
        Duloxetine (Cymbalta)
                                          Patient with psychomotor
   Heterocyclics
                                           retardation may receive a
      Bupropion (Wellbutrin),             drug with less sedative effect
        Mirtazapine (Remeron)              (Townsend, 2008)
Pharmacological Treatment of
Manic, Hypomanic, & Mixed Episodes
   Mood Stabilizers
       Lithium (Lithane), Gabapentin (Neurontin)
       Lithium most commonly used
           1-3 weeks to reach therapeutic levels
           Narrow therapeutic index, test blood levels weekly until
            therapeutic level is reached
           Side Effects: drowsiness, dizziness, HA, dry mouth, thirst, GI
            upset, polyuria, weight gain, hand tremors (Townsend, 2008)
   Anticonvulsants
      Carbamazepine (Tegretol),
    Clonazepam (Klononpin), Valporic
    Acid (Depakote)
   Calcium Channel Blockers
       Verapamil (Calan; Isoptin)
   Antipsychotics
     Aripiprazole (Abilify), Quetiapine
    (Seroquel), Risperidone (Risperdal)
Therapeutic Treatment Options
   Psychotherapy
     Individual; more successful in
    depressive episodes
     Family-Focused Psychoeducational
    Treatment (FFT)
   Cognitive Therapy
      Clients taught to control thought
    distortion
   Group Therapy
       Useful once past acute phase
       Support and self-help groups
   Family Therapy
       Indicated when marriage or family functioning is
        jeopardized or when they perpetuate the disorder
   Electroconvulsive
       For severe, unresponsive depressive episodes, and
        occasionally acute mania
Family Support
   Take care of self
   Learn about bipolar disorder
   Recognize the warning signs
   Encourage client to continue treatment
   Maintain health care appointments
   Consistent use of medicine
   Support alcohol/drug-free lifestyle
   Don’t take rejection personally
   Encourage counseling, support groups
   Empower client
   Create a safety plan

   Remember your support can make a big difference to the
    person living with bipolar

    Support + Treatment = Hope
Nursing Interventions
 Reinforce worth of the client by
assisting in:
     Evaluation of positive, negative
    aspects of life
     Expression of angry feelings
     Schedule recreational/occupational therapy and self-
      grooming
     Administration of mood stabilizing medications
   Interpersonal therapies, cognitive-behavioral
    therapy
   Group therapy, journal episodes
   Take suicide precautions if necessary
   Client teaching

Lehne, R. (2004). Pharmacology for Nursing Care. Missouri: Saunders Varcarolis,
  E. (2002). Foundations of Psychiatric Mental Health Nursing: A Clinical
  Approach. Pennsylvania: Saunders.
Prognosis
Prognosis: Factors
Accurate Diagnosis                Good Treatment                  Good Prognosis
   Can be a severely disabling medical condition BUT many
    individuals with bipolar disorder live full, satisfying lives
   Depends on many factors:
       right medications at right dose
       an informed patient
       good working relationship with a competent medical doctor and
        therapist
       supportive family or significant other
       secure finances and housing
       balanced lifestyle (regulated stress level, exercise, sleep/wake
        times)
   Factors that lead to good prognosis & reduce recurrence:
       awareness of small changes in one's energy, mood, sleep and
        eating behaviors
       having a plan in conjunction with one's doctor for how to manage
        subtle changes that might indicate the beginning of a mood swing
            keeping a log of moods can assist in predicting changes
Prognosis: Recovery
   Low rate of recovery, high rate of recurrence, & poor
    interepisodic functioning
   Most costly category of mental disorders in the United
    States
Recovery Statistics
 50% achieved syndromal recovery (no longer meeting
  criteria for diagnosis) within 6 weeks; 98% within 2
  years
 72% achieved symptomatic recovery (no symptoms)
 43% achieved functional recovery (regaining prior
  occupational & residential status)
 40% went on to experience new episode of mania or
  depression within 2 years of syndromal recovery
 19% switched phases without recovery
Prognosis: Mortality
                  Suicide rate 10-20
                   times higher than
                   general population
                  Bipolar II: higher
                   suicide rates than
                   other mental illnesses,
                   including major
                   depression
Media Portrayals
Lifetime Movie Network
Britney Spears
Media Portrayals of Bipolar Disorder
NEGATIVE                         POSITIVE

   Stigma                          Education
   Reinforces Stereotypes          Personalizes Mental Illness
   Exploitative                    Empathetic
   Perpetuates Myths               Raises Public Awareness
   Feeds Public’s Fears            Patient Advocacy
   Internalized Hopelessness       Offers Images of Hope
   Barrier to Accessing            Reducing Barriers to Treatment
    Treatment

• How can nurses play an important role in dispelling negative or
inaccurate depictions of mental illness?
TV portrayals
 ER (2000 – 2006)
Sally Field played Maggie, the manic-
  depressive mother of resident
  medical student Abby Lockhart
  (Maura Tierney). Maggie suffers
  from Bipolar Type I, with major
  manic episodes and major
  depressive episodes.
http://www.youtube.com/watch?v=BIxj6k8U7_0




 • Even though she (Sally Field’s character) was fixing to go off the deep-end, it
 made me want to feel that high feeling again and quit living in a zombie tired
 state. So I went off my medicine….
                                     -“Katygirl13”, About Bipolar Disorder Forum
                                http://forums.about.com/n/pfx/forum.aspx?webtag=ab-bipolar
Films
        The Devil and                 The Bridge (2007)
        Daniel Johnston
        (2005)                        Documentary on
                                      suicide and the Golden
        Documentary of                Gate Bridge, featuring
        musician/artist with          an interview with
        bipolar disorder.             bipolar survivor Kevin
        http://www.youtube.com/watc   Hines.
        h?v=2qtFPOxDMs4               http://www.youtube.com/watch
                                      ?v=T5ZJ637ep9U



        Grey Gardens                  Stephen Fry: The
        (1975)                        Secret Life of a
                                      Manic Depressive
        Documentary of “Little        (2006)
        Edie” and her mother
        “Big Edie” – the              BBC documentary on
        reclusive aunt and            bipolar disorder
        first cousin of Jackie        featuring actor
        Onassis.                      Stephen Fry and other
        http://www.youtube.com/watc   interviews.
        h?v=rEfvh_xTFBA               http://www.youtube.com/watc
                                      h?v=_nXgZlvjkAo
Books
Kay Redfield Jamison
Clinical psychologist and writer who is one of the foremost experts on bipolar
    disorder, having suffered from the disorder since her early twenties. She is
    Professor of Psychiatry at Johns Hopkins University School of Medicine.

                 An Unquiet Mind: A Memoir of Moods and Madness

                 With breathtaking honesty she tells of her own manic depression,
                 the bitter costs of her illness, and its paradoxical benefits: "There
                 is a particular kind of pain, elation, loneliness and terror involved
                 in this kind of madness.... It will never end, for madness carves
                 its own reality."


                 Touched with Fire: Manic Depressive Illness and the
                 Artistic Temperament

                 An examination of the correlation between creativity and bipolar
                 disorder. Does treatment of psychiatric symptoms blunt the
                 ability of the artist to work successfully?
 (a very small and subjective sampling of)

 Individuals with Bipolar Disorder




Patty Duke, actress       Carrie Fisher, actress       Alvin Ailey, Dancer          Edvard Munch, artist




                                                                                     Jane Pauley, news anchor
Jackson Pollock, artist         Sylvia Plath, author      Emily Dickinson, author
Resources
   www.mayoclinic.com/health/bipolardisorder/DS00356/DSECTION=symptoms
   searchwarp.com/swa138146.htm
   www.dbsalliance.org
   www.bipolar.com
   www.mentalhealthcare.org.uk/content/?id=153
   www.bipolarworld.net/Phelps/ph_2000/ph8.htm
   www.medicinenet.com/bipolar_disorder/page4.htm#tocg
   www.cnsforum.com/imagebank/item/genetics_bipolar_x/default.aspx
   www.pendulum.org/disease.htm
   www.sciencedaily.com/releases/2006/05/060530090014.htm
   www.psycheducation.org/BipolarMechanism/2BrainDifferences.htm
   encarta.msn.com/media_461539689/brain_activity_in_bipolar_disorder.html
   www.bipolar-lives.com/bipolar-brain-imaging.html
   www.johnclarkson.com.au/images/brainmapping/bipolar_brain.jpg
   Copstead, L., & Banasik, J. (2005.) Pathophysiology. St. Louis, MO: Elsevier.
   Lehne, R. (2004). Pharmacology for Nursing Care. Missouri: Saunders
   Varcarolis, E. (2002). Foundations of Psychiatric Mental Health Nursing: A Clinical
    Approach. Pennsylvania: Saunders.
   Famous People with Bipolar Disorder, Bipolar Disorder Today website. Retrieved
    November 2, 2008 from www.mental-health-today.com/bp/famous_people.htm
   Levin, Aaron; Violence and Mental Illness: Media Keep Myths Alive; Psychiatric News,
    May 4, 2001, Volume 36, Number 9; American Psychiatric Association
   Mental Health and the Media (2003), Lichtenstein Creative Media: Creating Media
    that Matters. Retrieved November 2, 2008 from www.lcmedia.com/mind279.htm
   Read, Kimberly & Marcia Purse, Bipolar Disorder Comes to ER (2006); About.Com
    Bipolar Disorder Forum. Retrieved November 2, 2008 from
    bipolar.about.com/od/mediaportrayals/a/aa001127a.htm
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