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 Questions?