Bipolar Disorder - Diagnosis and Treatment - Research Paper Example

?Running head: Diagnosis and Treatment of Bipolar Disorder Bipolar Disorder: Diagnosis and Treatment Number: of of Institution: Name of Instructor: 2013 Abstract Bipolar disorder is a psychiatric illness that is most prevalent in the adolescent period but also affects adults. Early intervention should be applied as it may result into serious symptoms, like death of the patient. The World Health Organization considers BD as a leading cause of disability. One of the most common symptoms for BD is depression, though clinicians described mania and hypomania as the common symptoms. Mania includes behavioural and cognitive wherein the patient displays symptoms of pressured speech and reduced sleep and other symptoms that reduce the quality of life. Hypomania is shorter in duration than mania. Intervention of BD includes treatment at the earliest signs of the illness. Treatment is effective if there is combined pharmacotherapy and psychosocial therapy. This means in addition to medication, treatment needs understanding of biological and psychosocial factors, such as dealing with stress, patient’s social environment, and continuous medication. There were several treatment techniques introduced in this essay. One example is the complementary and alternative medicine, which includes traditional therapy like acupuncture and naturopathy or herbal medicine. CAM can provide physical and mental health and improve quality of life. Treatment should be introduced in a quiet and stimulating environment, with appropriate nursing care in order to reduce the symptoms. The drug quetiapine or lamotrigine is recommended for early treatment. For patients who have had mania, anti-manic agent is recommended but not antidepressant monotherapy because of a possible switch to mania. Treatment should also consider the prevention of recurrence, or preventing a relapse following a severe manic episode. Psychological support coupled with social support is recommended. Introduction Major morbidity and mortality characterize bipolar disorder, a serious psychiatric disorder. It is regarded by the World Health Organization as one of the leading causes of disability. In its early stage, it triggers suicide attempts and severe symptoms include functional impairment due to “persistent neurocognitive deficits”. Aggressive and effective treatment is needed for this kind of psychiatric illness. (Calkin & Alda, 2012, p. 437) Bipolar disorder affects about one to two percent of adults and can increase up to four percent. There are four types of bipolar disorder (BD) as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR): bipolar I, bipolar II, cyclothymia, and not otherwise (NOS) specified. All these four types have one key characteristic which is manic or hypomanic episode (American Psychiatric Association, 2000, as cited in Loganathan, Lohano, Roberts, Gao, & El-Mallakh, 2010, p. 682). Depression is the first symptom of this disease and is most prevalent during adolescence, around the age 17. Normally, diagnosis is delayed for about 12.5 years. The delay in diagnosis can be explained in the fact that during the first onset, a depressive mood is seen and mania is seen at a later onset. If there is diagnosis delay, then treatment is also delayed. A disadvantage to this delay is that lithium becomes less effective. Lithium when administered early has greater response on the part of the patient as per studies by Swann and colleagues. (Berk et al., 2010, p. 116) Mixed mania is a distinct characteristic of bipolar I, and described by Loganathan et al. (2010) as “a state in which a full manic episode is superimposed on a full depressive episode – a depression with all the energy and force of a mania” (p. 683). This means as the mania progresses, it increases 12-fold, with more depression and dysthymia. A manic occurrence includes symptoms considered behavioural and cognitive, or the patient has pressured speech, mixed thoughts, low self-esteem and quick-tempered, indulge in pleasurable acts, and reduced sleep (Sarris et al., 2011, p. 883). Hypomania is present in bipolar II disorder (Goodwin, 2009, p. 355). Causes for this enfeebling disease include personal and social factors, while effective but non-conservative type of treatment can provide an improved quality of life, reduce symptoms and side-effects, and the patient becomes cooperative in the treatment process (Sarris, Lake, & Hoenders, 2011, p. 881). The term hypomania is defined differently by writers. Goodwin (2009) states that the definition of the term is significant to the diagnosis of bipolar I disorder. Hypomania has a shorter occurrence of 4 days and patients exhibit observable behaviour but not with impairment. In some definitions, hypomania is associated with obstruction from personal function, which means it is one form of mild mania. On the other hand, not otherwise specified (NOS) classification has been attributed to about 2.4% community incidence. NOS includes hypomania with the occurrence of a major depression; hypomania that occurs for at least 2 episodes but without major depression; and “recurrent subthreshold hypomania” (Goodwin, 2009, p. 358). Thesis statement: Bipolar disorder, a psychiatric illness that threatens adolescents, must be treated with a combination of pharmacotherapy and dealing with psychosocial factors of the patient. Diagnosis It is the responsibility of clinicians to make an accurate diagnosis of this sickness before treatment can be effectively done. Accurate diagnoses and differentiation should be introduced on symptoms of “hypomania, mania and mixed states”, which are properly guided and provided in the checklist by the American Psychiatric Association DSM-IV. First, BD patients can be diagnosed as having depression. Anxiety disorders are distinct features and can increase the pain and burden of BD. In Goodwin’s (2009) evidence-based guidelines, diagnosis comes first and foremost, followed by availability of services and safety of the ill person. This should be accompanied with increased care by formulating a therapeutic cooperation, educating both the patient and the clinician, and enhancing a treatment bond between the two. Another important factor should be knowledge of the stressors and other symptoms, and evaluating and managing outcomes, like impairments. (Goodwin, 2009) Most onsets of BD are signs of depression that can change into BD, but this has to be differentiated from severe depression during diagnosis. Symptoms are not enough in the process of this differentiation; clinical facts have to be noted and included in the process. These facts may include the age of onset of depression, frequency of suicidal ideation, cyclothymic and irritable temperaments. In O’Donovan et al.’s (as cited in Calkin et al., 2012) study, patients with BD II were younger and had more atypical features. They found that early onset of depression gave way to the identification of more than 90 percent of patients with future BD. The most common first diagnosis is unipolar depression but there are other signs related to personality disorder, like anxiety and substance abuse. Inappropriate therapy should be avoided, such as “manic switching and cycle acceleration with antidepressants” (Berk et al., 2010, p. 116). Depression is prevalent in bipolar disorder. Features of BD include hypersomnia or “increased daytime napping”, and such other symptoms like “leaden paralysis” and hyperphagia, psychotic symptoms such as pathological guilt, slowing of the psychomotor nerves, and so on. (Berk et al., 2010) Intervention There have been attempts of prevention in psychiatric disorders, but intervening before onset of the illness has not been effective. What clinicians have done successfully is secondary intervention, i.e. to intervene at the earliest period the illness is recognized. It was based on the treatment of schizophrenia and eventually psychosis (McGorry et al., 1996, as cited in Berk et al., 2010, p. 114). What is focused in early intervention is the idea that BD is progressive and follows a predictable occurrence. Clinicians provide the concept of staging model which states that people with illness progress “through a series of identifiable steps, each with its own characteristic features and treatment implications” (Berk et al., 2007; McGorry, 2006, as cited in Berk et al., 2010, p. 114). First, there is stage 0, which is described as the time focused on individuals who have risk factors, but as yet have not manifested perceived symptoms. These risk factors include genetic, pregnancy and obstetric complications, childhood psychological, physical and sexual abuse, substance abuse, and so on. (Berk et al., 2010) The next is stage 1 where symptoms are identified. Stage 2 starts when mania is identified and hypomania for bipolar II is also seen. It is in this stage that intervention must be undertaken to prevent any damage the illness can provide. Stage 3 is the time when recurrence of the illness is present. In this stage, clinicians note the “recurrence of subthreshold symptoms”; then, these threshold symptoms occur, followed by “repeated persistent relapses or by the rapid-cycling subtype” (Berk et al., 2010, p. 115). In stage 4, there is persistent unremitting nature of BD, and treatment includes the drug clozapine, with aggressive combination strategies and ECT. (Berk et al., 2010) Treatment Treatment of bipolar disorder in adolescents becomes effective with a combined medication and psychosocial therapy (Kowatch & DeBello, 2006, as cited in Crowe et al., 2008, p. 142). There has to be an early intervention because with early symptoms, patients can be obstructed in their “social, neurobiological, cognitive and emotional development” (Miklowitz 2004, p. 113). Treatment needs understanding of biological and psychosocial factors. This method was used in a psychotherapy model known as Interpersonal Social Rhythm Therapy (IPSRT) which was introduced in conjunction with medications. According to this concept, psychosocial factors act upon biology to create pathways for BD’s recurrence, and these pathways are: 1) stressful life events, (2) disruptions in social life and (3) medication non-adherence. These factors are interrelated. IPSRT is a manual-based psychotherapy that focuses on: mood and happenings in life; maintaining regular daily rhythms with the use of a Social Rhythm Matrix (SRM); identification of interpersonal relations; emphasizing the loss of healthy self; and identification and management of BD symptoms. IPSRT looks at the interpersonal relationships and how they affect mood, behavioural strategies made to focus on daily routines and psycho education to help patients cope with their sickness and understand their predicament. (Crowe et al., 2008, p. 142) Complementary and Alternative Medicine (CAM) This is another type of therapy which includes some traditional (Chinese) medicine like acupuncture or naturopathy or herbal medicine. About 50 percent of psychiatric patients use this kind of treatment, with sectors like women, the seniors, and even the educated people, using it quite often. Others apply it with a combination of pharmacotherapies. CAM can provide a good number of benefits including physical and mental health, and improved quality of life. (Sarris et al., 2011, p. 881) Treatment of the different phases of bipolar disorder Acute manic or mixed episodes In the treatment process, a quiet and stimulating environment, with appropriate nursing care, can reduced acute behaviour in some patients. For those not yet on long-term treatment and with manic or mixed episodes, the patient should be given antipsychotic or valproate to treat the rapid anti-manic effect (Goodwin, 2009, p. 350). A short-term treatment, such as lithium or CBZ, can be administered for patients with less ill manic symptoms. For those with reduced sleep, benzodiazepine can be administered. If symptoms continue even with optimized doses and mania still is severe, it is recommended to add another medicine, such as a combination of lithium or valproate with an antipsychotic (Goodwin, 2009, p. 352). Acute depressive episode The drug quetiapine or lamotrigine is recommended for early treatment. For patients who have had mania, anti-manic agent is recommended but not antidepressant monotherapy because of a possible switch to mania. For patients who exhibit psychotic signs, anti-psychotic drugs can be added. Electro-convulsive therapy (ECT) is recommended for patients who exhibit manic symptoms. This is also considered for patients with suicidal tendencies, psychosis, severe depression or life-threatening situations. Long term treatment The process of treatment should focus on prevention of recurrence, or preventing a relapse following a severe manic episode. Psychological support coupled with social support is recommended. Even when the patient is considered well, it should be noted that there is still the possibility of relapse which still remains high. In this situation, long-term agents are recommended, for example drugs called mood stabilizers to prevent a relapse. Continuous treatment is needed for long-term goals to prevent a recurrence. When a stressor is seen, there should be short-term medication, such as benzodiazepines or antipsychotics, in order to deal with early symptoms of relapse. (Goodwin, 2009, p. 354) Motivational interviewing Motivational interviewing (MI) is used in clinical practice “to improve patients’ attitudes and insight as well as their adherence to treatment” (Tay, 2007; Rusch & Corrigan, 2002, as cited in Laakso, 2012, p. 8). Medication non-adherence is the failure of patients to regularly take their prescribed medications. This can be intentional or unintentional, but there are other factors, such as financial factors, lack of health insurance coverage, problems with access to health care and poor relationships with clinicians or health providers. Patient non-adherence to medication is a problem since this can have a high impact on patients’ health and well-being, as well as society in general. It will also trigger a relapse or recurrence of the BD symptoms and may result into more treatment and hospitalization. Mental health nurses should be able to use motivational interviewing effectively as this can help patients improve their adherence to psychotropic medication. (Laakso, 2012, p. 8) Conclusions Bipolar disorder should be everyone’s concern, particularly those with increased risk. Aggressive and effective treatment is needed with long-term goals to prevent the recurrence of the symptoms. The symptoms are somewhat similar to depression and the patient can be mistakenly diagnosed as being depressed. Based on studies, BD has to be accurately diagnosed since there were many instances wherein patients had to be diagnosed up to four times before clinicians concluded that the sickness was BD. Delay of diagnosis should be avoided since treatment of lithium becomes less effective. Treatment needs understanding of biological and psychosocial factors. Expert studies point to a combination of several techniques in the treatment of BD. This process includes medication and dealing with psychosocial factors. Psychosocial factors heavily affect our biological make up, for example, if we are submitted to a stressful life, and there is increased risk if BD runs in the genes, or if we have a family history of the disease. As proven in the studies, BD is most common in adolescence because it is in this period that adolescents are most susceptible to a stressful life and where genes exhibit its early biological characteristics. References Berk, M., Hallan, K., Malhi, G., Henry, L., Hasty, M., MacNeil, G.,...McGorry, P. (2010). Evidence and implications for early intervention in bipolar disorder. Journal of Mental Health, 19(2), 113-126. doi: 10.3109/09638230903469111 Calkin, C. & Alda, M. (2012). Beyond the guidelines for bipolar disorder: Practical issues in long-term treatment with lithium. The Canadian Journal of Psychiatry, 57(7), 437-445. Retrieved from ABI/INFORM Complete database. Crowe, M., Inder, M., Joyce, P., Moor, S., Carter, J., & Luty, S. (2008). A developmental approach to the treatment of bipolar disorder: IPSRT with an adolescent. Journal of Clinical Nusing, 18, 141-149. doi: 10.1111/j.1365-2702.2008.02571.x Goodwin, G. (2009). Evidence-based guidelines for treating bipolar disorder: revised second edition-recommendations from the British Association for Psychopharmacology. Journal of Psychopharmacology, 23(4), 346-388. doi: 10.1177/0269881109102919 Laakso, L. (2012). Motivational interviewing: Addressing ambivalence to improve medication adherence in patients with bipolar disorder. Issues in Mental Health Nursing, 33, 8-14. doi: 10.3109/01612840.2011.618238 Loganathan, M., Lohano, K., Roberts, R., Gao, Y., & El-Mallakh, R. (2010). When to suspect bipolar disorder. The Journal of Family Practice, 59(12), 682-688. Retrieved from http://www.jfponline.com/index.php?id=22143&tx_ttnews[tt_news]=175606 Miklowitz, D., George, E., Axelson, D., Kim, E., Birmaher, B., & Scneck, C. (2004). Family-focused treatment for adolescents with bipolar disorder. Journal of Affective Disorders, 82, 113-128. Retrieved from ABI/INFORM Complete database. Sarris, J., Lake, J., & Hoenders, R. (2011). Bipolar disorder and complementary medicine: Current evidence, safety issues, and clinical considerations. Journal of Alternative and Complementary Medicine, 17(10), 881-890. doi: 10.1089/acm.2010.0481 Read More