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Management of Bipolar Disease

Special considerations needed when working with the elderly, females and caregivers.

To view the Course Outline and take the exam online, click here.

For a printer-friendly version of the exam you can print out, complete and mail to ADVANCE, click here.

Learning Scope #387
1 contact hour
Expires June 18, 2014

You can earn 1 contact hour of continuing education credit in three ways: 1) Grade and certificate are available immediately after taking the online test. 2) Send the answer sheet (or a photocopy) to ADVANCE for Nurses, Learning Scope, 2900 Horizon Dr., King of Prussia, PA 19406. 3) Fax the answer sheet to 610-278-1426. If faxing or mailing, allow 30 days to receive certificate or notice of failure. A certificate of credit will be awarded to participants who achieve a passing grade of 70 percent or better.

Merion Matters is an approved provider of continuing nursing education by the Pennsylvania State Nurses Association (No. 221-3-O-09), an accredited approver by the American Nurses Credentialing Center's Commission on Accreditation. 

Merion Matters is also approved as a provider by the California Board of Registered Nursing (No. 13230) and by the Florida Board of Nursing (No. 3298).

The goal of this continuing education offering is to provide nurses with current information on managing bipolar disease. After reading this article, you will be able to:

1. Describe the presentation and treatment of bipolar disorder.
2. Explain the importance of treating coexisting conditions.
3. Discuss the impact of bipolar disorder in special populations, including the elderly, women and caregivers of children with bipolar disorder.

  • The author has completed a disclosure form and reports no relationships relevant to the content of this article.

Nurses face many challenges when they work with people with bipolar disorder. At any given time, these patients may have distortions of mood and thoughts, slip into suicidal depression, or experience uncontrollable highs that in some cases can lead to psychosis.

This article reviews bipolar disorder and focuses on special considerations when working with the elderly, women and caregivers of children with the condition.

Overview of Bipolar Disorder

Bipolar disorder is a chronic mental illness that causes a person to experience periodic mood swings from depression to mania. It occurs in about 4 percent of American adults.1 Approximately 2 percent of children of elementary and middle-school age have bipolar disorder.2

The prevalence of bipolar disorder in the elderly population is predicted to increase significantly as the baby boomer generation grows older. As many as 10 percent of inpatient psychiatric admissions among older adults are for bipolar disorder.3

Symptoms of bipolar disorder are the symptoms of mania and depression. They may be mild with infrequent illness episodes to severe, rapid cycling of symptoms, which can be severely debilitating.

Mania is characterized by:

• restlessness and racing thoughts resulting in racing speech;
• excessive energy and a sense of euphoria;
• irritability and distractibility;
• reduced need for sleep;
• poor judgment, grandiosity and poor judgment; and
• provocative, intrusive or aggressive behavior.4

Depression is characterized by:

• changes in appetite and sleep;
• fatigue and loss of energy or irritability and restlessness;
• lack of concentration and problems making decisions;
• hopelessness, worthlessness and feelings of guilt; and
• thoughts of death or suicide.

Treatment Options

The impact of bipolar disorder on individuals can be quite severe. Like other chronic illnesses, bipolar disorder requires lifelong management.

Research shows people with bipolar disorder who are treated with medication and intensive psychotherapy have fewer relapses and lower hospitalization rates, and are better able to comply with their treatment plans.5

  • Lithium carbonate (Eskalith or Lithobid) is effective in controlling symptoms of mania and preventing the recurrence of manic and depressive episodes.
  • Valproic acid or divalproex sodium (Depakote) is a popular alternative to lithium carbonate.
  • The anticonvulsant lamotrigine (Lamictal) is approved for maintaining mood stability in the treatment of bipolar disorder.
  • Other anticonvulsant medications, including gabapentin (Neurontin), topiramate (Topamax) and oxcarbazepine (Trileptal), also are prescribed to treat bipolar disorder.

Atypical antipsychotic medications are sometimes used to treat symptoms during the manic episodes of bipolar disorder. Olanzapine (Zyprexa), aripiprazole (Abilify), quetiapine (Seroquel), risperidone (Risperdal) and ziprasidone (Geodon) have all been used to relieve symptoms of severe mania or psychosis, as well as for maintenance treatment.

Fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft) and bupropion (Wellbutrin) are examples of antidepressants that may be prescribed to treat symptoms of depression.1

Electroconvulsive therapy may be considered as a treatment option for individuals with bipolar disorder who do not respond to other interventions.


In a Cochrane systematic review, St. John's wort (Hypericum perforatum) extracts were noted to be "similarly effective as standard antidepressants, and had fewer side effects than standard antidepressants."6 However, it is important for nurses to provide counseling to their patients about St. John's wort extract.

Those considering taking it need to know commercially produced products of St. John's wort extract vary in strength; it may cause symptoms of mania; and St. John's wort extract may reduce the effectiveness of other medications, including some antidepressant and anticonvulsant medications.7

Although there is insufficient evidence to support the use of omega-3 fatty acids in the treatment of bipolar disorder, "some positive benefits were found for [treating] depressive symptoms." No adverse events have been reported. Nurse need to individualize their care when working with someone who wants to take omega-3 fatty acids. Given the general health benefits and safety of omega-3, there is no reason to discourage patients from taking them.8

Research shows SAMe (S-Adenosylmethionine) to be useful for the treatment of depressive episodes in people with bipolar disorder. However, SAMe has a high risk for inducing mania or hypomania. SAMe is not an herb or a hormone. It's a naturally occurring molecule formed in the body from methionine and adenosine triphosphate. Nurses can educate their patients that taking SAMe adds to that normally produced by their bodies.9 Because SAMe may induce a manic episode, it is important nurses counsel their patients to notify them or their treating clinician if they are considering taking it.

Coexisting Conditions

Nurses working with people who have bipolar disorder need to make sure all coexisting disorders are discovered and treated. These include:

  • Substance abuse, as some people with bipolar disorder self-treat with alcohol or drugs; anxiety disorders, such as post-traumatic stress disorder and social phobia.
  • Attention deficit hyperactivity disorder (ADHD), which has some symptoms that overlap with bipolar disorder, such as restlessness and being easily distracted. Children and teens may be difficult to diagnose as symptoms of ADHD and bipolar disorder are similar.
  • Higher risk for developing hypothyroidism. Taking lithium carbonate increases the risk.
  • Migraine headaches, heart disease, diabetes and obesity.

Older Adults

Bipolar disorder is seen more often among older adults between ages 60 and 64 and the incidence declines gradually as age increases.10,11 Suicide risk is a considerable problem because as many as 19 percent of older adults with bipolar disorder successfully complete suicide. Adults older than age 50 are known to have more episodes of agitation during periods of depression.

Vascular mania has been identified in the older population. It occurs in older adults with a comorbid neurologic disorder, usually cerebrovascular disease. However, head trauma, neuroendocrine disorders and brain tumors also have been associated with vascular mania. Older adults with vascular mania tend to have more episodes of psychosis.

Older adults with bipolar disorder are treated with the same medications as younger adults. However, nurses need to be aware of certain considerations:

• Lithium carbonate's narrow therapeutic range renders toxicity more of a potential problem in older patients. It is used less often in the elderly population because their kidney function is often compromised.

• Divalproex or valproic acid (Depakote) seems to be an effective, well-tolerated mood stabilizer for older adult patients. In recent years, it has been used more often in older patients than lithium. Evidence supports valproic acid may be less effective in reducing manic symptoms than olanzapine but may cause less sedation and weight gain.12

• The anticonvulsant gabapentin (Neurontin) is well-tolerated and effective for treating elderly people who have episodes of mania.

• The anticonvulsant lamotrigine (Lamictal) and lithium carbonate are both used for relapse prevention. Lamotrigine is superior to lithium in preventing relapse into depressive episodes.

Antipsychotics, often used to manage acute mania, may need to be administered in their intramuscular form to older adults who are severely agitated. Both haloperidol (Haldol) and the anti-anxiety medication lorazepam (Ativan) may be used in combination to achieve rapid control of severe agitation in older adults.


Women who take divalproex or valproic acid (Depakote) to treat bipolar disorder may be at higher risk of developing polycystic ovary syndrome (PCOS). Nurses need to monitor for and encourage their female patients to report symptoms of PCOS: obesity, excess body hair and disruptions in the menstrual cycle. Symptoms of PCOS improve after discontinuing the medication.1

Research shows lithium carbonate (Eskalith or Lithobid) to be the most effective medication for pregnant women with bipolar disorder, although it can cause heart problems in the fetus. Nurses need to advise female patients seeking to become pregnant they need to determine the risks and benefits of taking lithium carbonate during pregnancy. All medications taken to treat bipolar disorder pass through breast milk.1 Nurses must help their female patients decide whether or not to breastfeed.

Special Population: Caregivers

It usually takes 10 years before a correct diagnosis of bipolar disorder can be made in children.13 Typically, boys display more manic symptoms and girls display more symptoms of depression.14 Children with bipolar disorder are at risk for suicide. Successful suicide completion is often viewed as either an accident or seen as a result of lack of attention rather than suicide.15

Family dynamics can become complicated and roles blurred when a child in the family has bipolar disorder. Family members may not know how to react to their ill child, thus causing additional stress and tension within the family.16 Caring for a child's unpredictable behavior often consumes the caregivers' entire day and may cause exhaustion, which in turn impacts the caregivers' ability to have a life of their own.2 Some caregivers can't provide appropriate care for their child due the burden the care creates on the family. There may be overriding concern about their children's future. Some family members may feel ashamed about having a child with a mental illness. Financial hardship also is often cause additional stress.17

Nurses can help families who have a child member with bipolar disorder by educating them on the disease process and the treatment prescribed. Since treatment for bipolar disorder often involves multiple drugs, the importance of adhering to a medication regime - even if signs or symptoms subside - needs to be continuously stressed to the family/caregiver and the child.13

Nurses also can aid caregivers by helping them stay "emotionally connected with the ill child, retaining a sense of self and hope, and finding a way through the elaborate systems of care and treatment regimens."2

Nurses are in a unique position to recommend local support groups and counseling opportunities to caregivers. This gives them the opportunity to provide comprehensive care without interruption in treatment. For example, it is important for nurses to work together with emergency medical services for the safety of the child, particularly if there is suicidal ideation or past attempts.15

It is important to collaborate with other interdisciplinary team members as well as teachers and other community members who work with children with bipolar disorder.

Nurses also can help caregivers reduce their financial hardship. For example, nurses can help them find affordable medications and treatment options for both the bipolar disorder and other co-existing conditions if they exist.

Although bipolar disorder can be disruptive to individuals and their families, nurses can help patients and their loved ones in a variety of ways. Nurses can help them focus on treatment achievements and the patient's strengths. Allowing caregivers to get time away from their caregiving role and offering comfort and support when life challenges seem overwhelming are important aspects of the nursing role.

Many individuals with bipolar disorder lead fulfilling and enjoyable lives. Being reminded this is a potential outcome of treatment gives strength and hope in times of upheaval.

References for this article can be accessed here.

To view the Course Outline and take the exam online, click here.

For a printer-friendly version of the exam you can print out, complete and mail to ADVANCE, click here.

Joan M. Lorenz
is a clinical specialist in adult psychiatric mental health nursing who provides consultation and workshops on empowering teams and improving workplace environments.

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