Learning Outcomes
By the end of this section, you should be able to:
- 13.3.1 Identify the characteristics of drugs used to treat bipolar disorder.
- 13.3.2 Explain the indications, actions, adverse reactions, contraindications, and interactions of drugs used to treat bipolar disorder.
- 13.3.3 Describe nursing implications for drugs used to treat bipolar disorder.
- 13.3.4 Explain the client education related to drugs used to treat bipolar disorder.
Bipolar disorder is a complex brain-based illness with a primary characteristic of mood disturbance. Clients alternate between episodes of depression and mania. Depression was described in the beginning of this chapter. Mania involves a period of abnormally and persistently elevated or irritable mood and increased goal-directed activity or energy (American Psychiatric Association, 2022). During this period, at least three of the following symptoms are present: grandiosity, decreased need for sleep, more talkative, flight of ideas or racing thoughts, distractibility, increased activity or agitation, and excessive involvement in risky behaviors.
Most times, clients seek help when they are in the depressed stage. However, if a client has an undiagnosed bipolar disorder, putting them solely on an antidepressant can cause the client to experience one or more manic phases. There are two main subtypes of this disorder. Bipolar Type 1 is characterized by the occurrence of one or more manic episodes interspersed with major depression. Bipolar Type 2 is characterized by occurrence of one or more major depressive episodes accompanied by at least one manic or hypomanic episode (persistent irritability without euphoria) (NIMH, 2023a).
Lithium
Lithium is a naturally occurring metallic salt. It is used mainly to treat and prevent mania. It has historically been the “gold standard” mood stabilizer, effectively controlling manic episodes as well as decreasing the frequency and intensity of manic cycles (Volkmann et al., 2020). Lithium has a narrow margin of safety; even small increases in the dose could be toxic (Hedya et al., 2023). The goal is to initially maintain the serum lithium level between 0.6 and 1.2 mEq/L (Coryell, 2022). Target maintenance drug levels are closer to 0.6 mEq/L. Table 13.16 describes levels of lithium toxicity.
| Serum Drug Levels | Clinical Manifestations |
|---|---|
| 1.5–2.5 mEq/L | Lethargy, tremors, nausea, and vomiting |
| 2.5–3.5 mEq/L | Confusion, agitation, delirium, tachycardia, and hypertonia |
| >3.5 mEq/L | Coma, seizures, hyperthermia, and hypotension |
Adverse Effects and Contraindications
Lithium is excreted through the kidneys unchanged; therefore, adequate renal function is essential. Because lithium is tied to sodium resorption, any drug that affects sodium balance may alter lithium concentrations, leading to either treatment failure or toxicity. Examples include diuretics, NSAIDs, and angiotensin-converting enzyme (ACE) inhibitors. Lithium interacts with other medications including carbamazepine (CNS toxicity), neuromuscular blocking agents (prolonged effects), and other serotonergic drugs (serotonin syndrome). Addison’s disease is a contraindication because the person is losing more sodium through the kidneys due to the lack of aldosterone. The kidneys then will reabsorb lithium back into the bloodstream, which can quickly cause lithium toxicity. Lithium inhibits the synthesis and release of thyroid hormones, resulting in hypothyroidism. Theophylline increases the renal excretion of lithium, resulting in subtherapeutic effects.
Table 13.17 is a drug prototype table for mood stabilizers featuring lithium. It lists drug class, mechanism of action, adult and pediatric dosage, indications, therapeutic effects, drug and food interactions, adverse effects, and contraindications.
| Drug Class Mood stabilizer Mechanism of Action Affects the synthesis, release, and reuptake of acetylcholine, dopamine, GABA, and norepinephrine within the brain Stabilizes postsynaptic receptor sensitivity to neurotransmitters Has a neuroprotective effect on areas of the brain associated with mood by stimulating neuronal growth The exact mechanism of action is unknown |
Drug Dosage Immediate release (acute manic episodes): Adults: 300 mg orally 3 times daily; usual dose: 900–1800 mg/day orally in 3–4 divided doses. Extended release (maintenance dosage): Adults: 450 mg orally twice daily. Usual dose: 900–1800 mg/day orally in 2 divided doses. Children >12 years: 450 mg orally twice daily. Maintenance dose: 15–60 mg/kg/day orally 3 times daily. |
| Indications Treatment of active manic episodes Maintenance therapy to prevent or diminish the frequency and intensity of future manic episodes Therapeutic Effects Alters the sodium transport of nerve and muscle cells Inhibits the release of NE and dopamine from stimulated neurons Increases the intraneuronal stores of NE and dopamine Decreases intraneuronal content of second messengers, which allows it to selectively modulate the responsiveness of the hyperactive neurons |
Drug Interactions Diuretics Serotonergic agent Neuromuscular blocking agents Carbamazepine Lithium-iodide salt combination Theophylline Food Interactions Sodium intake Deficit fluid intake |
| Adverse Effects Nephrotoxic Neurotoxic Toxic to the thyroid gland (goiter) Weight gain Metallic taste Hand tremors Polyuria/polydipsia Nausea Vomiting Diarrhea Edema/weight gain Muscular weakness |
Contraindications Renal failure Cardiovascular insufficiency Addison’s disease Untreated hypothyroidism Children <12 years of age Pregnancy and breastfeeding Caution: Vomiting/diarrhea Increase or decrease of sodium intake Diaphoresis/dehydration Suicidal or impulsive clients Active infection with fever |
Clinical Tip
Atypical Antipsychotic for Bipolar Disorder
In December 2021, the FDA approved lumateperone (Caplyta) for bipolar depression. The drug is an atypical antipsychotic. It can be used as a monotherapy or in combination with lithium or valproate. It is available as a once-daily oral pill that needs no dose changes.
Antiseizure Medications
Selected antiseizure medications can be used to treat mood disorders, usually in combination with other medications. Please refer to Anticonvulsant Drugs and Drugs to Treat Epilepsy, Migraine Headaches, and Intracranial Emergencies for a more detailed discussion of antiseizure medications.
Table 13.18 lists common antiseizure medications and typical routes and dosing for adult and pediatric clients.
| Drug | Routes and Dosage Ranges |
|---|---|
| Carbamazepine (Tegretol) |
Adults and children >12 years: Initial dose: 200 mg orally twice daily (tablet); may increase by up to 200 mg/day in divided doses on a weekly basis. Maximum dose: 1200 mg in adults and 1000 mg in children 12–15 years. Therapeutic range: 4–12 mg/L. |
| Lamotrigine (Lamictal, Subvenite) |
Monotherapy: First 2 weeks, 25 mg/day orally; week 3, increase to 50 mg/day; week 5, increase to 100 mg/day; week 6, increase to 200 mg/day (maximum). As an adjunct to valproic acid: First 2 weeks, 25 mg orally every other day; week 3, increase to 25 mg/day; week 5, increase to 50 mg/day; week 6, increase to 100 mg/day. Therapeutic range: 3–14 mcg/mL (or titrated to therapeutic effect). |
| Valproic acid, divalproex sodium (Depakote, Depakote ER) |
Acute mania in adults: Initial dose: 250–500 mg 3 times daily; increase dose rapidly. Maximum dose: 60 mg/kg/day. Less acute mania in adults: Initial dose: 200–500 mg; titrate upward as tolerated. Therapeutic range: 50–125 mcg/mL. |
Nursing Implications
The nurse should do the following for clients who are taking mood stabilizers:
- Obtain baseline and periodic lab work including serum carbamazepine levels or serum lithium levels if indicated, CBC with differential, electrolytes, liver function tests, and thyroid-stimulating hormone (TSH) levels.
- Evaluate client’s medical history and ensure there are no renal or cardiac concerns. Obtain a baseline electrocardiogram.
- Assess for any indication of suicidal ideations. Institute suicide precautions for at-risk clients.
- Monitor temperature, heart rate/rhythm, respiratory status, and blood pressure periodically.
- Assess orientation, affect, reflexes, bowel sounds, amount of urine output, and lung sounds.
- Monitor client’s renal function while on lithium.
- If CNS effects occur, provide safety measures to prevent client injury.
- Monitor for decreased manic behavior and impulsivity.
- Provide client teaching regarding the drug and when to call the health care provider. See below for client teaching guidelines.
Client Teaching Guidelines
The client taking a mood stabilizer should:
- Contact the health care provider with the first signs of rash if taking carbamazepine or lamotrigine.
- Notify the health care provider with unusual and easy bruising, blood in the urine or stool, fever, sore throat, right upper quadrant pain, and jaundice.
- Consider an additional or alternate form of contraception because carbamazepine decreases the effectiveness of certain hormonal contraceptives.
- Drink 8–12 glasses of water daily to prevent dehydration, which could cause lithium toxicity. Also, maintain a consistent sodium intake.
- Be aware they can take lithium with food if they experience gastric irritation.
- Continue taking the medication as prescribed despite their symptoms subsiding because this type of therapy is long term.
- Notify the health care provider and stop taking the drug immediately if manifestations of overdose occur (vomiting, diarrhea, ataxia, tremor, drowsiness, and muscle weakness).
- Notify the health care provider if thinking about getting pregnant. Studies have shown that lithium can be harmful to the fetus.
- Follow the prescribed schedule for lab work to check appropriate serum drug levels.
The client taking a mood stabilizer should not:
- Spend time in the sun without sunscreen and other coverings.
- Drive or perform tasks requiring alertness and coordination until effects of carbamazepine are known.
- Increase their exercise routine during hot weather because this can increase the risk of dehydration and lithium toxicity.
- Abruptly stop lithium, to avoid negative manifestations.
- Take the morning dose of lithium until a blood sample has been obtained. (Blood should be drawn about 12 hours after the last lithium dose.)
- Alter dietary salt intake. If decreased, lithium toxicity can result. If increased, lithium will be subtherapeutic.