November 27, 2024 • 49 mins
Bipolar disorder (BD) is challenging to differentiate from other psychiatric conditions due to its complexity and spectral nature. In fact, approximately 70% of patients with BD are without an accurate diagnosis, evidence-based treatment and management. In this episode of NP Pulse, "Patient Centric Management of Bipolar Disorder: Best Practices for Screening, Diagnosis and Treatment," nurse practitioner (NP) experts Braden Kameg and Lisa Anderson discuss ways in which NPs in primary care, psychiatric and mental health settings may decrease diagnostic delays and avoid misdiagnoses.
Learning objectives for this activity include:
- Review the prevalence, pathophysiology and clinical gravity of BD.
- Examine evolving screening and assessment best practices to facilitate early and accurate differential BD diagnosis and linkage to treatment.
- Evaluate the evidentiary base for novel and recently approved BD pharmacotherapies, with a focus on tailored treatment planning for individual patients.
- Design data-driven and patient-centric treatment plans for BD that integrate patient-specific factors, disease-specific factors and actively incorporate the patient voice.
0.92 CE / 0.50 RX
To claim continuing education credit for this program, log in to the CE Center, search for this program by name, complete the post-test and evaluation and then enter the participation code at the end of the podcast.
A clinical reference tool in English and Spanish is available for download:
AANP_Bipolar_Clinician_Tool_English.pdf
AANP_Bipolar_Clinician_Tool_Spanish.pdf
This activity is supported by an independent educational grant from Alkermes
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:12):
From the American
Association of Nurse Practitioners,
I am nurse practitioner, nurse midwife,
and AANP educationspecialist, Cammie Hauser.
And I would like towelcome you to this edition
of NP Pulse, the voice of the
nurse practitioner.
(00:33):
NP Pulse
is a AANP’s official podcast,
bringing unique nurse practitioner voices
and expertise on issues that matter to NPs
and to our patients.
As always, be sure to subscribeto this podcast, share
with your colleagues and checkback often for conversations
with nurse practitioners
(00:53):
and healthcare leadersfrom across the nation.
In this edition of NP Pulse,NP specialist Lisa Anderson
and Brayden Kameg will discuss thechallenges of identification
and treatment of bipolar disorder.
Bipolar disorder is bothcomplex and spectral in nature.
So much so thatapproximately 70% of patients
(01:16):
with this conditionmay go years without an
accurate diagnosis,
evidence-based treatment and management.
This podcast titled“Patient-Centric Management
of Bipolar Disorder:
Best Practices for Screening Diagnosis
and Treatment” is designed so that NPs
in primary care, psychiatric
and mental health settingsmay decrease diagnostic delays
(01:40):
and provide timely life-altering treatment
for patients sufferingwith bipolar disorder.
Learning objectivesfor this podcast include
review the prevalence, pathophysiology,
and clinical gravity of bipolar disorder.
Examine evolving screening
and assessment bestpractices to facilitate early
and accurate differentialbipolar disorder diagnoses
(02:04):
and linkage to treatment.
Evaluate the evidentiary base for novel
and recently approved bipolardisorder pharmacotherapies
with a focus on tailoredtreatment planning
for individual patients.
And finally, design data-driven
and patient-centric treatmentplans for bipolar disorder
(02:24):
that integrates bothpatient specific factors
and disease specific factors,and actively incorporate
the patient voice.
Lisa and I are really excited
to be talking todayabout bipolar disorder.
We're going to start bybreaking down the criteria
and exploring what it means
for individuals living with this disorder.
(02:45):
To start, let's talk aboutwhat bipolar disorder is.
It's characterized bysignificant mood swings including
emotional highs, which can beknown as mania or hypomania
and lows, which areindicative of depression.
Understanding the diagnosticcriteria is crucial
for effective treatment.
So let's get into the specifics.
(03:06):
We'll be talking about the Diagnostic
and Statistical Manualof Mental Disorders,
or the DSM-5 thatprovides the framework
for diagnosing bipolar disorder.
Today we'll focus on thetwo most common types
of bipolar disorder,bipolar 1 and bipolar 2.
Although we'll briefly talk about cyclo
(03:27):
and unspecified mood disorders.
bipolar 1 is diagnosed whenthere has been at least one
manic episode.
A manic episode is defined as a period
of abnormally elevatedmood, increased activity,
or energy lasting at least one week
or any duration ifhospitalization is necessary.
(03:48):
Two, be diagnosed with bipolar 1.
These manic episodes can be preceded
or followed by either hypomanic
or major depressive episodes,
but they're not requiredfor the diagnosis.
Looking at bipolar 2,this type is characterized
by at least one major depressive episode
and at least one hypomanicepisode without having ever
(04:11):
experienced a full manic episode.
Hypomania is similar tomania, but it's less severe.
It's shorter lasting, lastingat least four consecutive days
as opposed to one week.
The symptoms itself
and will get into that alittle bit later, are identical
to bipolar 1 disorder,but they're milder
and they tend to be shorter lived.
(04:33):
For bipolar 2, thedepressive episodes do tend
to be more frequent, theycan be quite debilitating,
and it's important tonote that the absence
of a full manic episode is
what distinguishes bipolar 2 from bipolar 1.
Beyond these two typeswe also have cyclothymia
which involves numerousperiods of hypomanic symptoms
(04:55):
and depressive symptomslasting for at least two years
in adults. The symptomsdon't meet the full criteria
for either hypomania
or a major depressive episode.Diagnosing bipolar disorder,
it's nuanced. And thisoften involves ruling out
other conditions.
Symptoms can overlap withother mental health disorders.
(05:16):
You know, it's really important
to complete a comprehensive assessment,
thinking about clinical interviews,
mood charts when necessary
and when possible inputfrom family members.
Lisa will talk aboutthat in a few seconds.
I just wanna quickly coverwhat's a nuanced topic,
but a really important topic,
and that's the idea
of what's called anunspecified mood disorder.
(05:39):
These are often encounteredin clinical practice,
particularly when a patientpresents with mood symptoms
that cause distress,that cause impairment,
but don't really meet the criteria
for either major depressivedisorder or bipolar disorder.
What's interesting aboutunspecified mood disorders is the
fact these were actually removed
(06:00):
as a diagnosis from the DSM-5,
although they were addedback in 2022 in the DSM-5
text revisions.
Given the complexities of identifying
and diagnosing mood disorders, it was felt
that we did need this sortof gray area for people
who might not otherwise meet criteria.
This allows for flexibilityin diagnosis when clinicians
(06:24):
encounter cases that don'tfit neatly into any one
established category.
This is valuable in settings,you know, time is limited,
resources are limited, andwhen immediate care is needed.
That's a really greatbreakdown on the diagnostic
criteria, Brayden, butI'm a little bit curious.
Can you provide some moredetails about the ages
(06:47):
of when bipolar disorder first appears
and how common it is overall?
Absolutely. So researchindicates that about 2.8%
of adults living in the UnitedStates experience bipolar
disorder at some point in their life.
The onset typicallyoccurs in late adolescence
or early adulthood.
(07:07):
It affects both men and women.
The presentation might differslightly between genders.
The lifetime prevalentrates also vary slightly
between bipolar 1 and bipolar 2.
Bipolar 1, which just toreiterate, is characterized
by manic episodes is oftendiagnosed more frequently than
bipolar 2, which involves the hypomanic
(07:29):
and depressive episodes.
The age of onset for bipolar 1 is often in the late teens,
while bipolar 2 tends tomanifest a little bit later,
usually in the twenties or thirties.
As far as demographicfactors go, studies show
that bipolar disorder is presentacross all racial, ethnic
(07:50):
and socioeconomic groups.
There can be variationsin how symptoms manifest
and how individuals access treatment.
Individuals from lowersocioeconomic backgrounds may
experience more barriersin obtaining adequate care,
which can lead to eitherunderdiagnosis or misdiagnosis.
Thinking about the etiology,it's really multifactorial.
(08:13):
So we know that this canbe influenced by genetic,
neurological, and environmental factors.
Most importantly, geneticsplay a significant role.
There have been family studiesshowing that individuals
with a first degree relativewho has bipolar disorder
are at higher risk for developingthe disorder themselves.
(08:33):
The heratibility of bipolardisorder is around 60 to 80%,
which suggests a strong genetic component.
While there haven't been anyparticular genes identified
as causative. Neurobiologicalfactors also contribute
to etiology abnormalities inneurotransmitter systems like
serotonin, dopamine,
and norepinephrine caninfluence mood regulation.
(08:55):
Neuroimaging studies haverevealed structural, functional
differences in the brains of individuals
with bipolar disorder,particularly in areas related
to mood regulation oremotional processing.
Lastly, you know, it's important
to think about environmental factors,
stressful life events, trauma.
(09:17):
We'll hear a little bitabout that when we go over
differential diagnosis,and Lisa will cover that.
Other significant changesin people's environment,
stressors can trigger theonset of bipolar disorder.
Substance use disordersare also commonly comorbid
with bipolar and can reallycomplicate the clinical picture,
making it essential forpractitioners to assess
(09:38):
for these factors duringan initial evaluation
and at follow-up visits.
So with bipolar disorderaffecting, you know,
a fairly significantportion of the population,
understanding the specificsymptoms is critical.
Lisa, can you walk us through some
of the key distinctions inbipolar disorder, specifically
(10:00):
how mania and hypomania differ
and why that matters for diagnosis?
Absolutely, Brayden.
So understanding thedifferences between mania
and hypomania is key foran accurate diagnosis
and effective treatmentplanning, mania and hypomania.
The two key features ofbipolar disorder seem similar
(10:23):
but actually have reallyimportant distinctions.
Mania is a more intense experience,
often leading to majordisruptions in one's daily life.
People in a manic episodemight feel extremely energized,
talk rapidly, have grandiose ideas,
(10:43):
engage in risky behaviorslike excessive spending
or impulsive decisions,
and this heightened energy,activity, risky behaviors
and impulsivity can be so overwhelming
that it often requireshospitalization to keep a person safe
and stabilize their mood.
Now looking at hypomania,on the other hand,
(11:06):
they share similar symptoms,
but it is generally less intense
and much shorter in duration.
People experiencing hypomaniamight feel more energetic
or productive than usual
and may seem unusuallycheerful or irritable,
but they typically stayconnected to reality
(11:27):
and can still function in daily life.
Hypomania doesn't usuallyrequire hospitalization
and might even go unnoticed by others,
or sometimes it can be mistaken
for just having a good mood phase.
Thanks for breaking downthe differences between mania
and hypomania, Lisa.
That distinction reallymakes a difference in
(11:49):
how we approach diagnosis and treatment.
So speaking of some of these complexities,
bipolar disorder often comeswith additional comorbidities
and distinguishing those symptomscan be really challenging.
Could you walk us through someof these common comorbidities
and how we can differentiatetheir symptoms from those
of bipolar disorder?
(12:10):
Absolutely, Brayden.
Let's start with PTSD orpost-traumatic stress disorder.
PTSD can have mood shifts
that look like depressiveepisodes in symptoms
of hypervigilance or irritabilitymight mimic the energy
seen in manic episodes.
Sleep disturbances including nightmares,
(12:31):
are very common in both PTSD
and bipolar disorder, especially
during the depressive or manic phases.
However, a key differenceis that mood shifts
in PTSD are usually triggeredby traumatic reminders
and classic PTSD symptomslike flashbacks, avoidance
and hypervigilance.
(12:51):
These don't typically showup in bipolar disorder.
Interestingly, about 16to 40% of individuals
with bipolar disorderalso experience PTSD,
so it is a connection worth noting.
Next is ADHD or attentiondeficit hyperactivity disorder.
ADHD and bipolar disordercan overlap in terms
(13:15):
of high energy and impulsivity,which resemble mania
and concentration issues,
which can look like depressive symptoms.
However, ADHD symptoms are persistent
and constant rather thanepisodic like you would see
in bipolar disorder.
And ADHD doesn't includedepressive episodes
(13:36):
or grandiosity found in bipolar disorder.
Up to 20% of individuals
with bipolar disorder maymeet the criteria for ADHD,
so we should always considerthis possibility when
evaluating patients.
Borderline personalitydisorder is another disorder
that can be tricky to distinguishfrom bipolar disorder.
(13:58):
Borderline has intense rapid mood swings,
which can resemble the mood shifts
in bipolar disorder. Impulsivity
and risk-taking behaviors areseen in borderline personality
disorder and may overlapwith manic behaviors
and feelings of emptinessand can mirror depression.
However, borderline personalitydisorder has these mood
(14:21):
swings that are often triggeredby interpersonal conflicts
and are usually shorter in duration,
whereas bipolar moodepisodes are more sustained.
Borderline also includes astrong fear of abandonment
and unstable relationships,which are not really seen
(14:42):
or central to bipolar disorder.
About 10 to 20% of individuals
with bipolar disorder also have borderline
personality disorder.
So recognizing these distinctions is key.
Now onto substance usedisorders, mood instability
and risky behaviors associated
with substance use can resemble manic
(15:05):
or depressive episodes.
Withdrawal can mimic depression
and intoxication cansometimes look like mania.
However, with substance use disorders,
mood changes are typicallytied to intoxication
or withdrawal phases,
not independent episodeslike in bipolar disorder.
Substance cravings
and compulsive use are also central
(15:27):
to substance use disorders,
but are not part of bipolar disorder.
Still around 40 to 60% of individuals
with bipolar disorder alsohave a comorbid substance use
disorder, making it asignificant key factor to consider.
Lastly, we have depressionwith anxiety, a combination
(15:49):
that can mimic some aspectsof bipolar disorder.
Depression with anxiousfeatures can look like bipolar
depressive episodes
and anxiety that can causeirritability can overlap
with symptoms of hypomania or mania.
However, unlike bipolar disorder,
this combination lacks distinctmanic or hypomanic episodes.
(16:11):
The depressive episodes
in bipolar disorderalso have more pronounced
energy changes.
Anxiety is extremely commonin bipolar disorder with
around 70 to 90% of people
with bipolar disorderexperiencing anxiety symptoms.
Each of these comorbiditiesactually requires a very careful
(16:34):
assessment to separate them from
or recognize themalongside bipolar disorder,
as these distinctions are essential
for guiding our treatment approach.
So now that we've coveredsome key distinctions in
comorbidities and symptoms,Brayden, could you walk us
through the pharmacologicaltreatment options
for bipolar disorder?
How do these medications target both manic
(16:56):
and depressive symptoms?
Yeah, we'll start with lithium.
Lithium is one of the oldest
and most effective moodstabilizers used in the management
of bipolar disorder.
It consistently has beenshown to reduce the frequency
and severity of moodepisodes, including both manic
and depressive episodes.
(17:17):
However, managing lithiumtherapy requires careful
consideration and monitoring.
So we'll break down the key components
of lithium management.
First, it's crucial
to understand the indications for lithium.
It's primarily used in the treatment
of bipolar 1 disorder, particularly
for patients experiencingacute mania as well as
(17:39):
for long-term maintenanceto prevent mood episodes.
Lithium may also be used off-labelfor other conditions such
as treatment-resistant depression,
and some anxiety disorders.
Now let's discuss the dosingand titration of lithium.
The typical starting dosefor adults is usually
around 300 milligrams,two to three times a day
(18:03):
with adjustments madebased on serum levels in
clinical response.
If you're using off-label
for things like treatmentresistant depression,
that dosing might looka little bit different.
If you have somebody who's older
or who has medical comorbidities,
you can also start a littleslower at 300 milligrams at
bedtime and then increase as needed.
(18:23):
Lithium levels, thetherapeutic range is typically
between 0.6 to 1.2milliequivalents per liter,
depending on the individual
in the clinical scenario.
Monitoring ofserum lithium levels,
that is essential, especiallyin the early phases
of treatment. Levels shouldbe checked about every five
to seven days after initiation or
(18:45):
after dose adjustment untilstable levels are achieved.
Once stable,
the monitoring can be spacedout every three to six months.
Side effects are animportant consideration in
lithium management.
Common side effects caninclude tremors, weight gain,
increased thirst, some GI upset.
(19:06):
More serious concernsinclude renal impairment
and thyroid dysfunction.
So it's essential
to monitor renal function inthyroid levels periodically
throughout treatment.
Let's also touch on toxicity.
You know, recognizing andmanaging lithium toxicity.
Symptoms of toxicity can rangefrom mild such as diarrhea,
(19:28):
mild tremors to severe,including confusion, ataxia
and even seizures.
If toxicity is suspected,
immediate serum lithiumlevel testing is warranted
and management mayinclude adjusting the dose
or in some severe cases,hospitalization for IV fluids,
monitoring some cases even dialysis.
(19:52):
Depakote is anotherwell-established mood stabilizer
frequently used for managing acute mania
and for long-term maintenancetherapy in bipolar disorder,
its effectiveness
and tolerability make itan important option in
our treatment arsenal.
Depakote is primarilyindicated for the treatment
of manic episodes associatedwith bipolar disorder.
(20:15):
It can also be effective inpreventing future mood episodes
and is sometimes used off label
for other conditionslike migraine prophylaxis
or seizure disorders.
When initiating treatment, the dosing
of Depakote is crucial.
Starting dose for adults is typically
around 750 milligramsper day, divided into two
(20:37):
or three doses,
and then just like lithium,
that dose is adjustedbased on clinical response
and serum levels.
The therapeutic range for bipolardisorder, for serum levels
for Depakote is between 50 to125 micrograms per milliliter.
Again, depending on the individual's needs
and other underlyingmedical comorbidities,
(20:59):
monitoring is a criticalcomponent of Depakote management.
We should be checking theseserum levels regularly,
particularly within those firstfew months of treatment or
after any dose adjustments.
Liver function tests,
complete blood counts shouldalso be monitored periodically.
Depakote can be hepatotoxic,it can affect liver enzymes.
(21:20):
We can see lower platelet counts.
It's important to alsonote, you know, some
of the minor side effectsmight include GI upset,
weight gain, sedation,hair loss or alopecia.
More severe risks includehepatotoxicity, as I mentioned,
pancreatitis.
So really educatingpatients on these signs
(21:42):
and symptoms is critical.
Lastly, people
of childbearing age shouldbe counseled on the risks
of Depakote, particularlyregarding the fact
that it can have teratogenic effects.
So if you're working withpatients who can become pregnant
or who are trying to become pregnant,
having those discussions aboutcontraceptives if they're
prescribed Depakote is really important.
(22:05):
If you have somebody who isactively trying to get pregnant
or they are pregnant, lamotrigine
and some of the antipsychotics
that we'll talk abouta little bit later tend
to be safer options.
Lisa will cover some
of the antipsychotic medication shortly,
but I just wanna quicklytouch on lamotrigine.
It's an anti-convulsantmedication that is FDA approved
(22:26):
for bipolar maintenance.
It's particularly effectivefor bipolar depression.
It's titrated very slowly.
We start lamotrigine at 25milligrams daily for two weeks,
then we increase it to 50milligrams daily for two weeks,
and then we can furthertitrate it up to a dose
of typically 200 milligrams daily.
(22:46):
We follow this titrationschedule to reduce the risk
of Stevens Johnson syndrome.
As previously mentioned,
anti-psychotic medicationsalso play a significant role in
managing both acute
and long-term phases ofbipolar disorder, particularly
during manic episodes
or what we call mixedepisodes. Mood stabilizers,
(23:08):
the few I mentioned areoften considered first-line
treatments, but anti-psychoticscan be invaluable as well,
especially when rapidsymptom control is needed.
Lisa, can you walk us through the role
of antipsychotics in treatingbipolar disorder?
Absolutely, Brayden. So,
let's talk about antipsychotics that are
(23:29):
most commonly used totreat bipolar disorder,
especially when addressing manic episodes
or for maintaining moodstability over the long term.
Each medication has itsown profile of benefits,
side effects and monitoring needs.
So I'll kind of break this down
and give you all a clear understanding
(23:51):
of the different kinds ofantipsychotics starting
with typical or firstgeneration antipsychotics.
These are gonna be alittle bit more rare to use
for bipolar disorder,
but there are two of themthat are FDA approved
for bipolar disorder.
We have chlorpromazine and haloperidol.
(24:12):
Chlorpromazine is primarilyfor manic episodes.
Common side effectswould include sedation,
low blood pressure, dry mouth,and sometimes constipation.
Haloperidol on the otherhand, is often chosen
for acute manic episodesbecause it works pretty quickly,
(24:32):
but it does come with risk
for side effects like musclestiffness, restlessness,
and even tremors.
Now both of these first generationantipsychotics carry the
risk of extrapyramidal symptoms or EPS.
These are involuntary muscle movements.
This is why monitoring is so important
(24:55):
as when somebody startson these medications.
We need to regularlycheck for EPS symptoms,
monitor blood pressure,
and in some cases doregular blood tests to check
for any other side effects.
In terms of timing, patientsmay notice some initial
positive effects in about a few days,
but it can take two to fourweeks to see the full benefits.
(25:17):
So moving on to the secondgeneration antipsychotics,
this is a little bit more common.
What you'll see in practiceare these second generation
and in a little bit
Brayden will talk moreabout the newer meds.
But quetiapine is anotherversatile antipsychotic
that works across manic, mixed
and depressive episodesfor bipolar disorder.
(25:39):
Side effects here includesedation and weight gain.
So again, monitoringblood sugar, cholesterol
and weight are essential.
People tend to typically startto see a relief in symptoms
with quetiapine in about a week
with continued benefits over time.
Another one, asenapine is usedfor manic and mixed episodes.
(26:04):
This one's a pretty unique antipsychotic
because it is a sublingual tablet,
which some patients prefer.
Side effects can includedrowsiness, weight gain,
and changes in metabolism.
So it's important tokeep an eye on weight,
blood sugar and cholesterol.
Risperidone is another commonchoice for acute mania.
(26:25):
It may cause side effectslike drowsiness, restlessness,
quite a bit of weight gain
and so monitoring for thesealong with blood sugar
and cholesterol like theothers, is very important.
This one can also begin totake effect within a few days,
but the full therapeuticeffects may take a few weeks.
Ziprasidone is approved forboth manic and mixed episodes.
(26:49):
It is very well tolerated withfewer risk of weight gain,
which is a positive, but patientsmay experience drowsiness
or restlessness.
Monitoring weight is recommended here,
but what is most importantwith ziprasidone is a history
of cardiovascular symptoms as it can prolong
(27:11):
that QTc and so we needto keep an eye on that.
And if they have a heart condition
or a history of any heart conditions,
obtaining an EKG is probablybest practice before starting
ziprasidone. olanzapineis another frequently used
antipsychotic to treat manic episodes
(27:31):
and maintenance as well.
This one can cause significant weight gain
and sedation, so we need tokeep an eye on metabolic factors
with this particular medicationas well as blood sugar
because olanzapine can increase that.
It can start to work veryrapidly in about a week,
but it can take a few weeks.
(27:52):
Now what's really interestingabout olanzapine is
that there's a couple ofcombinations that I wanna bring
to your attention hereyou have this combination
of olanzapine and fluoxetine.
This is branded as Symbyax,which is specifically used
for depressive episodes associated
with bipolar 1 disorder.
(28:13):
While this combination is effective,
it can still cause the sideeffects like weight gain
and drowsiness and metabolic changes.
So you still have to monitorthose really closely.
The other combination worthmentioning is olanzapine
combined with samidorphan.
This is branded as Lybalvi.
This combines the anti-psychoticolanzapine with a compound
(28:36):
that reduces weight gain, samidorphan,
and this makes it a prettygood option for those
that have experiencedsignificant weight gain
with just olanzapine by itselfor with other antipsychotics
because of that activeingredient samidorphan.
However, because it has samidorphanin in it,
(28:56):
prescribers need to be mindful of any patients taking opioids
as samidorphan canprecipitate withdrawal due
to samidorphan blocking the receptors
that the opioids typically activate.
So that's something tobe very mindful about.
The last second generationantipsychotic I want
to briefly mention is iloperidone.
(29:17):
This antipsychotic has beenaround for over a decade,
but just received FDA approvalfor the acute treatment
of mania or mixed episodes ofbipolar 1 disorder in April
of 2024.
Like ziprasidone monitoringcardiovascular side effects is a
must as it can cause QTc elongation.
(29:40):
However, this is a twice day tablet
that can make it quite challenging
for medication adherence though.
But we have some new third generation
medications out there.
Brayden, can you tell us a littlebit more about those newer
antipsychotics approvedfor bipolar disorder?
Yeah, absolutely. Let's dive into some
(30:02):
of the newer antipsychotics.
Two of them, lurasidone
and lumateperone are similar to, you know,
they're in the same drug classas the second generations
that Lisa covered, but theywere more recently FDA approved
for bipolar disorder.
And then in addition to those,
we have two third generationantipsychotics, aripiprazole,
(30:24):
and cariprazine
that work a little bitdifferently rather than being
dopamine antagonists or blockers.
They are dopamine partial agonists
and we will talk aboutthat in a little bit.
So the four newer medicationsthat we're gonna cover,
aripiprazole, lurasidone,cariprazine and lumateperone.
(30:45):
These medications bring someunique benefits as it relates
to tolerability while stillmanaging mood symptoms.
So starting with aripiprazole,which is a third generation,
it's FDA approved formanic and mixed episodes
and can also be used forlong-term maintenance
in bipolar 1 disorder.
As I mentioned, aripiprazoleis a partial dopamine agonist,
(31:07):
which means it modulatesdopamine rather than
fully blocking it.
The partial agonist effect isone reason aripiprazole tends
to have fewer issues with sedation
and weight gain compared tosome of the previous options
that Lisa had covered.
That said, we can still see weight gain,
particularly in children and adolescents,
(31:28):
and we may see sideeffects like restlessness,
insomnia, and nausea.
Unlike the secondgeneration antipsychotics,
which fully block dopaminearipiprazole’s partial
agonism approach allows
for mood stabilization withouta heavy impact on metabolism.
Lurasidone is approved specifically
(31:49):
for depressive episodes inbipolar 1 disorder, either
as monotherapy or in combinationwith lithium or valproate,
Depakote. Lurasidone is a secondgeneration antipsychotic.
It's known for its relativelymild side effect profile,
particularly regarding weightgain and metabolic impacts.
If you have somebody who'sconcerned about weight gain,
(32:12):
this really can be preferred.
Side effects includesome nausea, drowsiness,
but you know, we don'tsee the weight changes,
we don't see the metabolic symptoms such
as elevated cholesterol
or elevated blood sugarthat we may see with some
of the older secondgeneration anti-psychotics.
This can be a reallyappealing choice for people
(32:33):
who have concerns aboutthe metabolic symptoms.
One of the downsides isit does have to be taken
with food typically 350 calories.
And so you know, I have foundsome patients that find that
to be difficult just toincorporate into their routine.
There's cariprazine, whichhas a versatile profile.
(32:53):
It's actually FDA approved
for bipolar disorder acrossthe continuum for bipolar 1.
And what we mean by thatis it has indications
for manic, mixed and depressiveepisodes in bipolar 1.
The mechanism is similar to aripiprazole.
It's in that third generation category in
that it's a partial agonistat dopamine receptors.
(33:14):
It has a stronger effect oncertain dopamine receptor
subtypes, specificallydopamine 3 receptors.
This gives it a little bit ofan edge in treating both manic
and depressive symptoms,especially if they're mixed,
which means they'reoccurring concurrently.
It does have some of the sameside effects like restlessness
(33:34):
that can be sort ofprominent with cariprazine.
It usually does improve with time.
Some people will have sometransient GI symptoms like
nausea, but compared with some
of the other agents we've talked about,
the way it targets dopaminemodulation really reduces the
risk of sedation and weight gain.
Finally, there's lumateperone.
(33:56):
This is a newer medication
that was fairly recently FDA approved
for treating depressiveepisodes in bipolar 1
and two disorder.
This medication's unique
because it acts on dopaminereceptors in addition
to serotonin and glutaminergic receptors.
So this multi receptor approachis thought to contribute
to some of the efficacy
(34:17):
for mood symptoms while stillhaving a smaller impact on
weight and metabolic issues like some
of these other medications
that we have just been highlighting.
The side effects tendto be mild, drowsiness,
dry mouth can be common,
but overall this can be anice option for somebody
who has those metabolic concerns.
(34:40):
So to summarize some ofthese newer medications,
aripiprazole, lurasidone, cariprazine,
and lumateperone each havedifferent FDA approvals within
bipolar disorder, whetherthat be for mania, mixed episodes,
depressive episodes.
What really sets themapart though, the four
that I have just coveredis the reduction in risk
(35:02):
of weight gain and metabolic symptoms due
to their more targeted receptor actions.
In general though, betweenthe mood stabilizing agents
and the antipsychoticsacross the spectrum,
we have a pretty broadtoolkit to tailor treatment
to each patient's needs while managing
some of the side effects.
That can be really challenging with some
(35:23):
of the typical antipsychoticsthat Lisa briefly mentioned.
Thanks forthat really great overview
of the newer antipsychotics, Brayden.
It's actually really helpful to see
how these newer options canmake such a difference in
managing bipolar symptomswith much fewer side effects.
(35:44):
Now, shifting gears just alittle bit, I would love
to hear your insightson antidepressants in
bipolar disorder.
How are they used
and what should clinicianskeep in mind when
considering them for treatment?
Thanks. Yeah, so antidepressants,
they can indeed play arole in the management
(36:06):
of bipolar disorder, particularly
for those experiencingsevere depressive episodes.
However, using antidepressantsfor a patient diagnosed
with bipolar disorderrequires careful consideration
and very close monitoring
because there is a riskwith antidepressants,
particularly serotonergic antidepressants,
(36:27):
that it can trigger mania or hypomania.
So when are antidepressantsappropriate, right?
We often use them more so in cases
of bipolar 2 disorderrather than bipolar 1.
In bipolar 2, the depressiveepisodes can be prominent,
they can be debilitating.
So it's not uncommon for us to augment
(36:50):
with an antidepressant forsomebody with bipolar 2
if they are already on a moodstabilizer in bipolar 1,
you know, we're less likelyto use an antidepressant
unless perhaps the patient hasa comorbid anxiety disorder
and they are also on mood stabilizers.
But the risk of using anantidepressant in bipolar 1 is
(37:12):
that somebody could then shiftfrom a depressive episode
into mania.
So for this reason, reallyhaving a thorough understanding
of the patient's mood history,their current symptoms,
what has their past responsebeen to previous medications.
There are some patients thatantidepressants aren't suitable
for, right?
(37:33):
Not all patients
with bipolar disorder willbenefit from an antidepressant.
So using
that individualizedpatient-centered approach is key.
Some antidepressantsare safer than others,
so I mentioned some of theserotonergic antidepressants,
the SSRIs, the SNRIs, they are more likely
(37:53):
to precipitate potentiallyworsening symptoms
or switch to mania
or hypomania compared
to medications like bupropiondon't work on serotonin might
be an antidepressant that'spreferred for somebody
with bipolar disorder.
Again, assuming that theyare already on something else
to stabilize their mood.
(38:15):
Tailoring that treatment planto the patient's history,
their symptom profile.
I mentioned some people withbipolar disorder might have
comorbid anxiety
and in that case they maybenefit from an antidepressant
that also has an anxietyindication if their mood's
otherwise stabilized.
But we really wanna work with the patient
to achieve stability, achieve remission,
(38:36):
while minimizing risks.
So with that, ideallyantidepressants should be paired
with a mood stabilizer
or some sort of atypical anti-psychotic
to help reduce the riskof mood cycling or mania.
So to wrap up thispharmacological approach
to bipolar disorder, we'vecovered mood stabilizers,
we've covered anti-psychotics.
(38:58):
We've talked about cautious
and conservative use ofantidepressants within the framework
that prioritizes individualizedand patient-centered care.
That said, we knoweffective treatment goes
beyond just medication.
Lisa, can you share some insightson the non-pharmacological
interventions that can beespecially beneficial in managing
(39:20):
bipolar disorder?
Sure thing, Brayden.
So non-pharmacologicalstrategies are equally vital
for a well-rounded approach for treatment.
Now let's dive into three keylifestyle management factors
that are essential
for supporting overallwellbeing in someone
(39:42):
with bipolar disorder.
Treating bipolar disorder goes
beyond medications like Brayden discussed.
It's about addressing that entire person,
the whole person.
First, paying attention to sleephygiene is critical.
Regular sleep helps regulatemood and energy levels.
(40:03):
Sticking to a consistent sleep schedule,
creating a calm bedtimeroutine and minimizing screens
and caffeine in the eveningcan all promote better rest
and reduce the risk of mood episodes.
Diet and nutrition are also key components
of lifestyle management.
A balanced diet rich inwhole foods like fruits
(40:26):
and vegetables, lean proteins
and whole grains provideessential nutrients
that support brain health.
Avoiding excessive sugar, caffeine,
and processed foods canhelp minimize energy spikes
and mood fluctuations.
Creating a more stablefoundation for daily life.
(40:46):
Physical activity is another vital piece.
Regular exercise doesn'tjust support physical health.
It also releases endorphinsthat boost mood, reduce anxiety
and improve sleep quality.
It doesn't have to be intense.
Even daily walks, yoga
or light strength training can make a
(41:07):
significant difference.
Establishing routines inthese areas, in sleep, diet
and exercise can help adults
with bipolar disorder createmore stability in their lives,
supporting overall wellness
and helping prevent extreme mood shifts.
Thanks for coveringthose lifestyle factors, Lisa.
(41:28):
Can you tell us moreabout the evidence-based
psychotherapy approachesthat are especially effective
for managing bipolar disorder?
Of course, Brayden,
and that's actually avery important component
that we really need to to consider
'cause evidence-based psychotherapyapproaches are crucial
for managing bipolar disorder effectively.
(41:50):
Each therapy addresses uniqueaspects of the condition,
helping patients gainbetter control over symptoms
and achieves stabilityjust beyond medications
and lifestyle changes.
First, we have psychoeducation.
This approach is allabout empowering patients
(42:10):
by providing detailedknowledge about bipolar itself.
Arguably, it's probablynot a psychotherapy,
but still critical to do this.
For every patient thathas bipolar disorder,
the primary goal with psychoeducation is
to build a solid rationale for seeking
(42:30):
and sticking with treatment.
By understanding the natureof their symptoms, the purpose
of the medications
and the potential side effects,
patients will feel more empowered
to handle stressful situations
and stay adherent to their treatment plan.
The focus here is on creatinga partnership in which
(42:51):
patients feel informed and and control.
So cognitive behavioral therapyis very common in bipolar
disorder as a psychotherapy modality.
This therapy works on theidea that thoughts, feelings,
and behaviors are interconnected
and influence one another,especially during mood episodes.
(43:13):
The main objective here isto help patients recognize
and change their thoughts, beliefs,
and behaviors that can triggeror worsen their symptoms.
Cognitive behavioral therapystrategies include helping
patients understand their condition,
develop practical copingskills, improve sleep routines,
(43:34):
and strengthen adherence to treatment.
It is a comprehensive approach
that offers concrete strategies
for managing symptoms day to day.
Another effective therapyis family focused therapy.
The foundation of thistherapy is that unsupportive
or negative family dynamicscan increase the patient's
(43:54):
stress and risk for mood episodes.
Family focused therapy aimsto reduce overall stress
by improving and support within the family
or primary relationships.
It emphasizes the importance
of understanding bipolar disorder,
including the stress vulnerability model
and medication adherence.
(44:16):
Concrete communication strategiessuch as active listening
and positive requests are taught
to foster a more supportive environment,
and you will often seefamily-focused therapy used more
frequently in adolescents
or children with pediatricbipolar disorder.
Lastly, interpersonal
(44:37):
and social rhythm therapyfocuses on creating stability in
daily routines and social interactions.
This therapy is based on the understanding
that irregular routines candisrupt circadian rhythms
triggering or worsening mood episodes.
The goal of interpersonal
and social rhythm therapyis to stabilize both mood
(45:00):
and circadian rhythms byaddressing interpersonal issues
and establishing regular daily habits.
Key strategies includelinking mood changes
with life events, grievingthe loss of a healthy self,
resolving primary interpersonal issues,
and maintaining consistent social rhythms.
(45:20):
Interpersonal social rhythmstherapy is probably the most
common psychotherapy modalityused in bipolar disorder
because it has a very strong evidence base
with its efficacy.
Each of these therapiesthough offer patients a very
structured approach tomanaging bipolar disorder
by targeting very specific symptoms
(45:42):
and their life areas that are problematic.
By incorporating a combination
of these evidence-based modalities,
we can help patientsachieve a more comprehensive
and resilient treatment plan.
Thanks for breaking downthose psychotherapy approaches.
Lisa, it can be helpful tocollaborate with therapists,
counselors, and othermental health professionals.
(46:05):
Do you have any insightabout collaboration
with primary care orother specialty providers?
Actually, yes Brayden. Collaboration
between primary care providers
and psychiatric mentalhealth nurse practitioners
or any other psychiatricclinician is actually essential
for managing bipolar disorder, especially
(46:27):
because of the high ratesof medical comorbidities
that often accompany the condition.
So patients with bipolardisorder are at an increased risk
for issues like cardiovasculardisease, diabetes,
and obesity, partly dueto the illness itself,
but also as a result of thepsychopharmacological treatments
(46:49):
that we implement.
Many of the medicationsused to stabilize mood such
as anti-psychotics
and mood stabilizerscan lead to weight gain,
metabolic syndrome,
and other side effects
that require careful medical oversight.
So it is very important
for the psychiatric mentalhealth nurse practitioner
(47:10):
to work closely with ourprimary care colleagues
that can help us monitorthose physical health risks
alongside mental health needs, ensuring
that patients receiveintegrated and holistic care.
This collaboration doesn'tjust address the symptoms
of bipolar disorder,
but it promotes overallhealth leading towards better
(47:32):
outcome and quality oflife for these patients.
Really valuable information.Thank you for sharing.
This has been such a great discussion, Brayden.
I think we have covered a lot
of important ground fromunderstanding the complexities
of the diagnosis to exploringboth pharmacological
and non-pharmacological treatments
(47:53):
that truly support patientswith bipolar disorder.
Yeah, it's so important
and so valuable to look atbipolar disorder from all angles,
especially since managing iteffectively really does require
a well-rounded, individualized approach.
I hope our listeners feelmore equipped with insights
(48:14):
that they can use andimplement into their practice.
Yes, and just remembering
that each patient's journey is unique
and may need a mix of treatments,whether it be medication,
psychotherapy,
or lifestyle management, itcan make a big difference.
Thank you for sharing yourexpertise on pharmacological
(48:35):
interventions, Brayden.
Yeah, thank you, Lisa,
for all your insights into the therapeutic
and lifestyle interventions.
It's been a pleasure workingthrough this with you.
And for our listeners,thank you for tuning in.
We hope that this discussion supports you
in providing compassionateinformed care to those
with bipolar disorder.
(48:55):
Definitely stay curious, keep learning,
and thank you for joining us.
Lisa, Brayden,
Thank you for this excellent podcast.
To our listeners, thankyou for visiting NP Pulse.
This program and the accompanyingclinical resource tool
were made possible by amedical education grant from
Alkermes Incorporated.
(49:17):
Continuing education creditfor this program may be claimed
through November 30th, 2025. Toclaim credit for the program,
login to CE Center at
aanp.org/cecenter,
search for this program byname and complete the post-test
and evaluation by enteringthe participation code
(49:39):
BIPOLAR24.
As always, thank you for theexcellent work you do every day
to take care of patients.
Your feedback is truly important to us.
From the American
Association of Nurse Practitioners,
I am nurse practitioner, nurse midwife,
and AANP educationspecialist, Cammie Hauser.
And I would like towelcome you to this edition
of NP Pulse, the voice of the
nurse practitioner.
(00:33):
NP Pulse
is a AANP’s official podcast,
bringing unique nurse practitioner voices
and expertise on issues that matter to NPs
and to our patients.
As always, be sure to subscribeto this podcast, share
with your colleagues and checkback often for conversations
with nurse practitioners
(00:53):
and healthcare leadersfrom across the nation.
In this edition of NP Pulse,NP specialist Lisa Anderson
and Brayden Kameg will discuss thechallenges of identification
and treatment of bipolar disorder.
Bipolar disorder is bothcomplex and spectral in nature.
So much so thatapproximately 70% of patients
(01:16):
with this conditionmay go years without an
accurate diagnosis,
evidence-based treatment and management.
This podcast titled“Patient-Centric Management
of Bipolar Disorder:
Best Practices for Screening Diagnosis
and Treatment” is designed so that NPs
in primary care, psychiatric
and mental health settingsmay decrease diagnostic delays
(01:40):
and provide timely life-altering treatment
for patients sufferingwith bipolar disorder.
Learning objectivesfor this podcast include
review the prevalence, pathophysiology,
and clinical gravity of bipolar disorder.
Examine evolving screening
and assessment bestpractices to facilitate early
and accurate differentialbipolar disorder diagnoses
(02:04):
and linkage to treatment.
Evaluate the evidentiary base for novel
and recently approved bipolardisorder pharmacotherapies
with a focus on tailoredtreatment planning
for individual patients.
And finally, design data-driven
and patient-centric treatmentplans for bipolar disorder
(02:24):
that integrates bothpatient specific factors
and disease specific factors,and actively incorporate
the patient voice.
Lisa and I are really excited
to be talking todayabout bipolar disorder.
We're going to start bybreaking down the criteria
and exploring what it means
for individuals living with this disorder.
(02:45):
To start, let's talk aboutwhat bipolar disorder is.
It's characterized bysignificant mood swings including
emotional highs, which can beknown as mania or hypomania
and lows, which areindicative of depression.
Understanding the diagnosticcriteria is crucial
for effective treatment.
So let's get into the specifics.
(03:06):
We'll be talking about the Diagnostic
and Statistical Manualof Mental Disorders,
or the DSM-5 thatprovides the framework
for diagnosing bipolar disorder.
Today we'll focus on thetwo most common types
of bipolar disorder,bipolar 1 and bipolar 2.
Although we'll briefly talk about cyclo
(03:27):
and unspecified mood disorders.
bipolar 1 is diagnosed whenthere has been at least one
manic episode.
A manic episode is defined as a period
of abnormally elevatedmood, increased activity,
or energy lasting at least one week
or any duration ifhospitalization is necessary.
(03:48):
Two, be diagnosed with bipolar 1.
These manic episodes can be preceded
or followed by either hypomanic
or major depressive episodes,
but they're not requiredfor the diagnosis.
Looking at bipolar 2,this type is characterized
by at least one major depressive episode
and at least one hypomanicepisode without having ever
(04:11):
experienced a full manic episode.
Hypomania is similar tomania, but it's less severe.
It's shorter lasting, lastingat least four consecutive days
as opposed to one week.
The symptoms itself
and will get into that alittle bit later, are identical
to bipolar 1 disorder,but they're milder
and they tend to be shorter lived.
(04:33):
For bipolar 2, thedepressive episodes do tend
to be more frequent, theycan be quite debilitating,
and it's important tonote that the absence
of a full manic episode is
what distinguishes bipolar 2 from bipolar 1.
Beyond these two typeswe also have cyclothymia
which involves numerousperiods of hypomanic symptoms
(04:55):
and depressive symptomslasting for at least two years
in adults. The symptomsdon't meet the full criteria
for either hypomania
or a major depressive episode.Diagnosing bipolar disorder,
it's nuanced. And thisoften involves ruling out
other conditions.
Symptoms can overlap withother mental health disorders.
(05:16):
You know, it's really important
to complete a comprehensive assessment,
thinking about clinical interviews,
mood charts when necessary
and when possible inputfrom family members.
Lisa will talk aboutthat in a few seconds.
I just wanna quickly coverwhat's a nuanced topic,
but a really important topic,
and that's the idea
of what's called anunspecified mood disorder.
(05:39):
These are often encounteredin clinical practice,
particularly when a patientpresents with mood symptoms
that cause distress,that cause impairment,
but don't really meet the criteria
for either major depressivedisorder or bipolar disorder.
What's interesting aboutunspecified mood disorders is the
fact these were actually removed
(06:00):
as a diagnosis from the DSM-5,
although they were addedback in 2022 in the DSM-5
text revisions.
Given the complexities of identifying
and diagnosing mood disorders, it was felt
that we did need this sortof gray area for people
who might not otherwise meet criteria.
This allows for flexibilityin diagnosis when clinicians
(06:24):
encounter cases that don'tfit neatly into any one
established category.
This is valuable in settings,you know, time is limited,
resources are limited, andwhen immediate care is needed.
That's a really greatbreakdown on the diagnostic
criteria, Brayden, butI'm a little bit curious.
Can you provide some moredetails about the ages
(06:47):
of when bipolar disorder first appears
and how common it is overall?
Absolutely. So researchindicates that about 2.8%
of adults living in the UnitedStates experience bipolar
disorder at some point in their life.
The onset typicallyoccurs in late adolescence
or early adulthood.
(07:07):
It affects both men and women.
The presentation might differslightly between genders.
The lifetime prevalentrates also vary slightly
between bipolar 1 and bipolar 2.
Bipolar 1, which just toreiterate, is characterized
by manic episodes is oftendiagnosed more frequently than
bipolar 2, which involves the hypomanic
(07:29):
and depressive episodes.
The age of onset for bipolar 1 is often in the late teens,
while bipolar 2 tends tomanifest a little bit later,
usually in the twenties or thirties.
As far as demographicfactors go, studies show
that bipolar disorder is presentacross all racial, ethnic
(07:50):
and socioeconomic groups.
There can be variationsin how symptoms manifest
and how individuals access treatment.
Individuals from lowersocioeconomic backgrounds may
experience more barriersin obtaining adequate care,
which can lead to eitherunderdiagnosis or misdiagnosis.
Thinking about the etiology,it's really multifactorial.
(08:13):
So we know that this canbe influenced by genetic,
neurological, and environmental factors.
Most importantly, geneticsplay a significant role.
There have been family studiesshowing that individuals
with a first degree relativewho has bipolar disorder
are at higher risk for developingthe disorder themselves.
(08:33):
The heratibility of bipolardisorder is around 60 to 80%,
which suggests a strong genetic component.
While there haven't been anyparticular genes identified
as causative. Neurobiologicalfactors also contribute
to etiology abnormalities inneurotransmitter systems like
serotonin, dopamine,
and norepinephrine caninfluence mood regulation.
(08:55):
Neuroimaging studies haverevealed structural, functional
differences in the brains of individuals
with bipolar disorder,particularly in areas related
to mood regulation oremotional processing.
Lastly, you know, it's important
to think about environmental factors,
stressful life events, trauma.
(09:17):
We'll hear a little bitabout that when we go over
differential diagnosis,and Lisa will cover that.
Other significant changesin people's environment,
stressors can trigger theonset of bipolar disorder.
Substance use disordersare also commonly comorbid
with bipolar and can reallycomplicate the clinical picture,
making it essential forpractitioners to assess
(09:38):
for these factors duringan initial evaluation
and at follow-up visits.
So with bipolar disorderaffecting, you know,
a fairly significantportion of the population,
understanding the specificsymptoms is critical.
Lisa, can you walk us through some
of the key distinctions inbipolar disorder, specifically
(10:00):
how mania and hypomania differ
and why that matters for diagnosis?
Absolutely, Brayden.
So understanding thedifferences between mania
and hypomania is key foran accurate diagnosis
and effective treatmentplanning, mania and hypomania.
The two key features ofbipolar disorder seem similar
(10:23):
but actually have reallyimportant distinctions.
Mania is a more intense experience,
often leading to majordisruptions in one's daily life.
People in a manic episodemight feel extremely energized,
talk rapidly, have grandiose ideas,
(10:43):
engage in risky behaviorslike excessive spending
or impulsive decisions,
and this heightened energy,activity, risky behaviors
and impulsivity can be so overwhelming
that it often requireshospitalization to keep a person safe
and stabilize their mood.
Now looking at hypomania,on the other hand,
(11:06):
they share similar symptoms,
but it is generally less intense
and much shorter in duration.
People experiencing hypomaniamight feel more energetic
or productive than usual
and may seem unusuallycheerful or irritable,
but they typically stayconnected to reality
(11:27):
and can still function in daily life.
Hypomania doesn't usuallyrequire hospitalization
and might even go unnoticed by others,
or sometimes it can be mistaken
for just having a good mood phase.
Thanks for breaking downthe differences between mania
and hypomania, Lisa.
That distinction reallymakes a difference in
(11:49):
how we approach diagnosis and treatment.
So speaking of some of these complexities,
bipolar disorder often comeswith additional comorbidities
and distinguishing those symptomscan be really challenging.
Could you walk us through someof these common comorbidities
and how we can differentiatetheir symptoms from those
of bipolar disorder?
(12:10):
Absolutely, Brayden.
Let's start with PTSD orpost-traumatic stress disorder.
PTSD can have mood shifts
that look like depressiveepisodes in symptoms
of hypervigilance or irritabilitymight mimic the energy
seen in manic episodes.
Sleep disturbances including nightmares,
(12:31):
are very common in both PTSD
and bipolar disorder, especially
during the depressive or manic phases.
However, a key differenceis that mood shifts
in PTSD are usually triggeredby traumatic reminders
and classic PTSD symptomslike flashbacks, avoidance
and hypervigilance.
(12:51):
These don't typically showup in bipolar disorder.
Interestingly, about 16to 40% of individuals
with bipolar disorderalso experience PTSD,
so it is a connection worth noting.
Next is ADHD or attentiondeficit hyperactivity disorder.
ADHD and bipolar disordercan overlap in terms
(13:15):
of high energy and impulsivity,which resemble mania
and concentration issues,
which can look like depressive symptoms.
However, ADHD symptoms are persistent
and constant rather thanepisodic like you would see
in bipolar disorder.
And ADHD doesn't includedepressive episodes
(13:36):
or grandiosity found in bipolar disorder.
Up to 20% of individuals
with bipolar disorder maymeet the criteria for ADHD,
so we should always considerthis possibility when
evaluating patients.
Borderline personalitydisorder is another disorder
that can be tricky to distinguishfrom bipolar disorder.
(13:58):
Borderline has intense rapid mood swings,
which can resemble the mood shifts
in bipolar disorder. Impulsivity
and risk-taking behaviors areseen in borderline personality
disorder and may overlapwith manic behaviors
and feelings of emptinessand can mirror depression.
However, borderline personalitydisorder has these mood
(14:21):
swings that are often triggeredby interpersonal conflicts
and are usually shorter in duration,
whereas bipolar moodepisodes are more sustained.
Borderline also includes astrong fear of abandonment
and unstable relationships,which are not really seen
(14:42):
or central to bipolar disorder.
About 10 to 20% of individuals
with bipolar disorder also have borderline
personality disorder.
So recognizing these distinctions is key.
Now onto substance usedisorders, mood instability
and risky behaviors associated
with substance use can resemble manic
(15:05):
or depressive episodes.
Withdrawal can mimic depression
and intoxication cansometimes look like mania.
However, with substance use disorders,
mood changes are typicallytied to intoxication
or withdrawal phases,
not independent episodeslike in bipolar disorder.
Substance cravings
and compulsive use are also central
(15:27):
to substance use disorders,
but are not part of bipolar disorder.
Still around 40 to 60% of individuals
with bipolar disorder alsohave a comorbid substance use
disorder, making it asignificant key factor to consider.
Lastly, we have depressionwith anxiety, a combination
(15:49):
that can mimic some aspectsof bipolar disorder.
Depression with anxiousfeatures can look like bipolar
depressive episodes
and anxiety that can causeirritability can overlap
with symptoms of hypomania or mania.
However, unlike bipolar disorder,
this combination lacks distinctmanic or hypomanic episodes.
(16:11):
The depressive episodes
in bipolar disorderalso have more pronounced
energy changes.
Anxiety is extremely commonin bipolar disorder with
around 70 to 90% of people
with bipolar disorderexperiencing anxiety symptoms.
Each of these comorbiditiesactually requires a very careful
(16:34):
assessment to separate them from
or recognize themalongside bipolar disorder,
as these distinctions are essential
for guiding our treatment approach.
So now that we've coveredsome key distinctions in
comorbidities and symptoms,Brayden, could you walk us
through the pharmacologicaltreatment options
for bipolar disorder?
How do these medications target both manic
(16:56):
and depressive symptoms?
Yeah, we'll start with lithium.
Lithium is one of the oldest
and most effective moodstabilizers used in the management
of bipolar disorder.
It consistently has beenshown to reduce the frequency
and severity of moodepisodes, including both manic
and depressive episodes.
(17:17):
However, managing lithiumtherapy requires careful
consideration and monitoring.
So we'll break down the key components
of lithium management.
First, it's crucial
to understand the indications for lithium.
It's primarily used in the treatment
of bipolar 1 disorder, particularly
for patients experiencingacute mania as well as
(17:39):
for long-term maintenanceto prevent mood episodes.
Lithium may also be used off-labelfor other conditions such
as treatment-resistant depression,
and some anxiety disorders.
Now let's discuss the dosingand titration of lithium.
The typical starting dosefor adults is usually
around 300 milligrams,two to three times a day
(18:03):
with adjustments madebased on serum levels in
clinical response.
If you're using off-label
for things like treatmentresistant depression,
that dosing might looka little bit different.
If you have somebody who's older
or who has medical comorbidities,
you can also start a littleslower at 300 milligrams at
bedtime and then increase as needed.
(18:23):
Lithium levels, thetherapeutic range is typically
between 0.6 to 1.2milliequivalents per liter,
depending on the individual
in the clinical scenario.
Monitoring ofserum lithium levels,
that is essential, especiallyin the early phases
of treatment. Levels shouldbe checked about every five
to seven days after initiation or
(18:45):
after dose adjustment untilstable levels are achieved.
Once stable,
the monitoring can be spacedout every three to six months.
Side effects are animportant consideration in
lithium management.
Common side effects caninclude tremors, weight gain,
increased thirst, some GI upset.
(19:06):
More serious concernsinclude renal impairment
and thyroid dysfunction.
So it's essential
to monitor renal function inthyroid levels periodically
throughout treatment.
Let's also touch on toxicity.
You know, recognizing andmanaging lithium toxicity.
Symptoms of toxicity can rangefrom mild such as diarrhea,
(19:28):
mild tremors to severe,including confusion, ataxia
and even seizures.
If toxicity is suspected,
immediate serum lithiumlevel testing is warranted
and management mayinclude adjusting the dose
or in some severe cases,hospitalization for IV fluids,
monitoring some cases even dialysis.
(19:52):
Depakote is anotherwell-established mood stabilizer
frequently used for managing acute mania
and for long-term maintenancetherapy in bipolar disorder,
its effectiveness
and tolerability make itan important option in
our treatment arsenal.
Depakote is primarilyindicated for the treatment
of manic episodes associatedwith bipolar disorder.
(20:15):
It can also be effective inpreventing future mood episodes
and is sometimes used off label
for other conditionslike migraine prophylaxis
or seizure disorders.
When initiating treatment, the dosing
of Depakote is crucial.
Starting dose for adults is typically
around 750 milligramsper day, divided into two
(20:37):
or three doses,
and then just like lithium,
that dose is adjustedbased on clinical response
and serum levels.
The therapeutic range for bipolardisorder, for serum levels
for Depakote is between 50 to125 micrograms per milliliter.
Again, depending on the individual's needs
and other underlyingmedical comorbidities,
(20:59):
monitoring is a criticalcomponent of Depakote management.
We should be checking theseserum levels regularly,
particularly within those firstfew months of treatment or
after any dose adjustments.
Liver function tests,
complete blood counts shouldalso be monitored periodically.
Depakote can be hepatotoxic,it can affect liver enzymes.
(21:20):
We can see lower platelet counts.
It's important to alsonote, you know, some
of the minor side effectsmight include GI upset,
weight gain, sedation,hair loss or alopecia.
More severe risks includehepatotoxicity, as I mentioned,
pancreatitis.
So really educatingpatients on these signs
(21:42):
and symptoms is critical.
Lastly, people
of childbearing age shouldbe counseled on the risks
of Depakote, particularlyregarding the fact
that it can have teratogenic effects.
So if you're working withpatients who can become pregnant
or who are trying to become pregnant,
having those discussions aboutcontraceptives if they're
prescribed Depakote is really important.
(22:05):
If you have somebody who isactively trying to get pregnant
or they are pregnant, lamotrigine
and some of the antipsychotics
that we'll talk abouta little bit later tend
to be safer options.
Lisa will cover some
of the antipsychotic medication shortly,
but I just wanna quicklytouch on lamotrigine.
It's an anti-convulsantmedication that is FDA approved
(22:26):
for bipolar maintenance.
It's particularly effectivefor bipolar depression.
It's titrated very slowly.
We start lamotrigine at 25milligrams daily for two weeks,
then we increase it to 50milligrams daily for two weeks,
and then we can furthertitrate it up to a dose
of typically 200 milligrams daily.
(22:46):
We follow this titrationschedule to reduce the risk
of Stevens Johnson syndrome.
As previously mentioned,
anti-psychotic medicationsalso play a significant role in
managing both acute
and long-term phases ofbipolar disorder, particularly
during manic episodes
or what we call mixedepisodes. Mood stabilizers,
(23:08):
the few I mentioned areoften considered first-line
treatments, but anti-psychoticscan be invaluable as well,
especially when rapidsymptom control is needed.
Lisa, can you walk us through the role
of antipsychotics in treatingbipolar disorder?
Absolutely, Brayden. So,
let's talk about antipsychotics that are
(23:29):
most commonly used totreat bipolar disorder,
especially when addressing manic episodes
or for maintaining moodstability over the long term.
Each medication has itsown profile of benefits,
side effects and monitoring needs.
So I'll kind of break this down
and give you all a clear understanding
(23:51):
of the different kinds ofantipsychotics starting
with typical or firstgeneration antipsychotics.
These are gonna be alittle bit more rare to use
for bipolar disorder,
but there are two of themthat are FDA approved
for bipolar disorder.
We have chlorpromazine and haloperidol.
(24:12):
Chlorpromazine is primarilyfor manic episodes.
Common side effectswould include sedation,
low blood pressure, dry mouth,and sometimes constipation.
Haloperidol on the otherhand, is often chosen
for acute manic episodesbecause it works pretty quickly,
(24:32):
but it does come with risk
for side effects like musclestiffness, restlessness,
and even tremors.
Now both of these first generationantipsychotics carry the
risk of extrapyramidal symptoms or EPS.
These are involuntary muscle movements.
This is why monitoring is so important
(24:55):
as when somebody startson these medications.
We need to regularlycheck for EPS symptoms,
monitor blood pressure,
and in some cases doregular blood tests to check
for any other side effects.
In terms of timing, patientsmay notice some initial
positive effects in about a few days,
but it can take two to fourweeks to see the full benefits.
(25:17):
So moving on to the secondgeneration antipsychotics,
this is a little bit more common.
What you'll see in practiceare these second generation
and in a little bit
Brayden will talk moreabout the newer meds.
But quetiapine is anotherversatile antipsychotic
that works across manic, mixed
and depressive episodesfor bipolar disorder.
(25:39):
Side effects here includesedation and weight gain.
So again, monitoringblood sugar, cholesterol
and weight are essential.
People tend to typically startto see a relief in symptoms
with quetiapine in about a week
with continued benefits over time.
Another one, asenapine is usedfor manic and mixed episodes.
(26:04):
This one's a pretty unique antipsychotic
because it is a sublingual tablet,
which some patients prefer.
Side effects can includedrowsiness, weight gain,
and changes in metabolism.
So it's important tokeep an eye on weight,
blood sugar and cholesterol.
Risperidone is another commonchoice for acute mania.
(26:25):
It may cause side effectslike drowsiness, restlessness,
quite a bit of weight gain
and so monitoring for thesealong with blood sugar
and cholesterol like theothers, is very important.
This one can also begin totake effect within a few days,
but the full therapeuticeffects may take a few weeks.
Ziprasidone is approved forboth manic and mixed episodes.
(26:49):
It is very well tolerated withfewer risk of weight gain,
which is a positive, but patientsmay experience drowsiness
or restlessness.
Monitoring weight is recommended here,
but what is most importantwith ziprasidone is a history
of cardiovascular symptoms as it can prolong
(27:11):
that QTc and so we needto keep an eye on that.
And if they have a heart condition
or a history of any heart conditions,
obtaining an EKG is probablybest practice before starting
ziprasidone. olanzapineis another frequently used
antipsychotic to treat manic episodes
(27:31):
and maintenance as well.
This one can cause significant weight gain
and sedation, so we need tokeep an eye on metabolic factors
with this particular medicationas well as blood sugar
because olanzapine can increase that.
It can start to work veryrapidly in about a week,
but it can take a few weeks.
(27:52):
Now what's really interestingabout olanzapine is
that there's a couple ofcombinations that I wanna bring
to your attention hereyou have this combination
of olanzapine and fluoxetine.
This is branded as Symbyax,which is specifically used
for depressive episodes associated
with bipolar 1 disorder.
(28:13):
While this combination is effective,
it can still cause the sideeffects like weight gain
and drowsiness and metabolic changes.
So you still have to monitorthose really closely.
The other combination worthmentioning is olanzapine
combined with samidorphan.
This is branded as Lybalvi.
This combines the anti-psychoticolanzapine with a compound
(28:36):
that reduces weight gain, samidorphan,
and this makes it a prettygood option for those
that have experiencedsignificant weight gain
with just olanzapine by itselfor with other antipsychotics
because of that activeingredient samidorphan.
However, because it has samidorphanin in it,
(28:56):
prescribers need to be mindful of any patients taking opioids
as samidorphan canprecipitate withdrawal due
to samidorphan blocking the receptors
that the opioids typically activate.
So that's something tobe very mindful about.
The last second generationantipsychotic I want
to briefly mention is iloperidone.
(29:17):
This antipsychotic has beenaround for over a decade,
but just received FDA approvalfor the acute treatment
of mania or mixed episodes ofbipolar 1 disorder in April
of 2024.
Like ziprasidone monitoringcardiovascular side effects is a
must as it can cause QTc elongation.
(29:40):
However, this is a twice day tablet
that can make it quite challenging
for medication adherence though.
But we have some new third generation
medications out there.
Brayden, can you tell us a littlebit more about those newer
antipsychotics approvedfor bipolar disorder?
Yeah, absolutely. Let's dive into some
(30:02):
of the newer antipsychotics.
Two of them, lurasidone
and lumateperone are similar to, you know,
they're in the same drug classas the second generations
that Lisa covered, but theywere more recently FDA approved
for bipolar disorder.
And then in addition to those,
we have two third generationantipsychotics, aripiprazole,
(30:24):
and cariprazine
that work a little bitdifferently rather than being
dopamine antagonists or blockers.
They are dopamine partial agonists
and we will talk aboutthat in a little bit.
So the four newer medicationsthat we're gonna cover,
aripiprazole, lurasidone,cariprazine and lumateperone.
(30:45):
These medications bring someunique benefits as it relates
to tolerability while stillmanaging mood symptoms.
So starting with aripiprazole,which is a third generation,
it's FDA approved formanic and mixed episodes
and can also be used forlong-term maintenance
in bipolar 1 disorder.
As I mentioned, aripiprazoleis a partial dopamine agonist,
(31:07):
which means it modulatesdopamine rather than
fully blocking it.
The partial agonist effect isone reason aripiprazole tends
to have fewer issues with sedation
and weight gain compared tosome of the previous options
that Lisa had covered.
That said, we can still see weight gain,
particularly in children and adolescents,
(31:28):
and we may see sideeffects like restlessness,
insomnia, and nausea.
Unlike the secondgeneration antipsychotics,
which fully block dopaminearipiprazole’s partial
agonism approach allows
for mood stabilization withouta heavy impact on metabolism.
Lurasidone is approved specifically
(31:49):
for depressive episodes inbipolar 1 disorder, either
as monotherapy or in combinationwith lithium or valproate,
Depakote. Lurasidone is a secondgeneration antipsychotic.
It's known for its relativelymild side effect profile,
particularly regarding weightgain and metabolic impacts.
If you have somebody who'sconcerned about weight gain,
(32:12):
this really can be preferred.
Side effects includesome nausea, drowsiness,
but you know, we don'tsee the weight changes,
we don't see the metabolic symptoms such
as elevated cholesterol
or elevated blood sugarthat we may see with some
of the older secondgeneration anti-psychotics.
This can be a reallyappealing choice for people
(32:33):
who have concerns aboutthe metabolic symptoms.
One of the downsides isit does have to be taken
with food typically 350 calories.
And so you know, I have foundsome patients that find that
to be difficult just toincorporate into their routine.
There's cariprazine, whichhas a versatile profile.
(32:53):
It's actually FDA approved
for bipolar disorder acrossthe continuum for bipolar 1.
And what we mean by thatis it has indications
for manic, mixed and depressiveepisodes in bipolar 1.
The mechanism is similar to aripiprazole.
It's in that third generation category in
that it's a partial agonistat dopamine receptors.
(33:14):
It has a stronger effect oncertain dopamine receptor
subtypes, specificallydopamine 3 receptors.
This gives it a little bit ofan edge in treating both manic
and depressive symptoms,especially if they're mixed,
which means they'reoccurring concurrently.
It does have some of the sameside effects like restlessness
(33:34):
that can be sort ofprominent with cariprazine.
It usually does improve with time.
Some people will have sometransient GI symptoms like
nausea, but compared with some
of the other agents we've talked about,
the way it targets dopaminemodulation really reduces the
risk of sedation and weight gain.
Finally, there's lumateperone.
(33:56):
This is a newer medication
that was fairly recently FDA approved
for treating depressiveepisodes in bipolar 1
and two disorder.
This medication's unique
because it acts on dopaminereceptors in addition
to serotonin and glutaminergic receptors.
So this multi receptor approachis thought to contribute
to some of the efficacy
(34:17):
for mood symptoms while stillhaving a smaller impact on
weight and metabolic issues like some
of these other medications
that we have just been highlighting.
The side effects tendto be mild, drowsiness,
dry mouth can be common,
but overall this can be anice option for somebody
who has those metabolic concerns.
(34:40):
So to summarize some ofthese newer medications,
aripiprazole, lurasidone, cariprazine,
and lumateperone each havedifferent FDA approvals within
bipolar disorder, whetherthat be for mania, mixed episodes,
depressive episodes.
What really sets themapart though, the four
that I have just coveredis the reduction in risk
(35:02):
of weight gain and metabolic symptoms due
to their more targeted receptor actions.
In general though, betweenthe mood stabilizing agents
and the antipsychoticsacross the spectrum,
we have a pretty broadtoolkit to tailor treatment
to each patient's needs while managing
some of the side effects.
That can be really challenging with some
(35:23):
of the typical antipsychoticsthat Lisa briefly mentioned.
Thanks forthat really great overview
of the newer antipsychotics, Brayden.
It's actually really helpful to see
how these newer options canmake such a difference in
managing bipolar symptomswith much fewer side effects.
(35:44):
Now, shifting gears just alittle bit, I would love
to hear your insightson antidepressants in
bipolar disorder.
How are they used
and what should clinicianskeep in mind when
considering them for treatment?
Thanks. Yeah, so antidepressants,
they can indeed play arole in the management
(36:06):
of bipolar disorder, particularly
for those experiencingsevere depressive episodes.
However, using antidepressantsfor a patient diagnosed
with bipolar disorderrequires careful consideration
and very close monitoring
because there is a riskwith antidepressants,
particularly serotonergic antidepressants,
(36:27):
that it can trigger mania or hypomania.
So when are antidepressantsappropriate, right?
We often use them more so in cases
of bipolar 2 disorderrather than bipolar 1.
In bipolar 2, the depressiveepisodes can be prominent,
they can be debilitating.
So it's not uncommon for us to augment
(36:50):
with an antidepressant forsomebody with bipolar 2
if they are already on a moodstabilizer in bipolar 1,
you know, we're less likelyto use an antidepressant
unless perhaps the patient hasa comorbid anxiety disorder
and they are also on mood stabilizers.
But the risk of using anantidepressant in bipolar 1 is
(37:12):
that somebody could then shiftfrom a depressive episode
into mania.
So for this reason, reallyhaving a thorough understanding
of the patient's mood history,their current symptoms,
what has their past responsebeen to previous medications.
There are some patients thatantidepressants aren't suitable
for, right?
(37:33):
Not all patients
with bipolar disorder willbenefit from an antidepressant.
So using
that individualizedpatient-centered approach is key.
Some antidepressantsare safer than others,
so I mentioned some of theserotonergic antidepressants,
the SSRIs, the SNRIs, they are more likely
(37:53):
to precipitate potentiallyworsening symptoms
or switch to mania
or hypomania compared
to medications like bupropiondon't work on serotonin might
be an antidepressant that'spreferred for somebody
with bipolar disorder.
Again, assuming that theyare already on something else
to stabilize their mood.
(38:15):
Tailoring that treatment planto the patient's history,
their symptom profile.
I mentioned some people withbipolar disorder might have
comorbid anxiety
and in that case they maybenefit from an antidepressant
that also has an anxietyindication if their mood's
otherwise stabilized.
But we really wanna work with the patient
to achieve stability, achieve remission,
(38:36):
while minimizing risks.
So with that, ideallyantidepressants should be paired
with a mood stabilizer
or some sort of atypical anti-psychotic
to help reduce the riskof mood cycling or mania.
So to wrap up thispharmacological approach
to bipolar disorder, we'vecovered mood stabilizers,
we've covered anti-psychotics.
(38:58):
We've talked about cautious
and conservative use ofantidepressants within the framework
that prioritizes individualizedand patient-centered care.
That said, we knoweffective treatment goes
beyond just medication.
Lisa, can you share some insightson the non-pharmacological
interventions that can beespecially beneficial in managing
(39:20):
bipolar disorder?
Sure thing, Brayden.
So non-pharmacologicalstrategies are equally vital
for a well-rounded approach for treatment.
Now let's dive into three keylifestyle management factors
that are essential
for supporting overallwellbeing in someone
(39:42):
with bipolar disorder.
Treating bipolar disorder goes
beyond medications like Brayden discussed.
It's about addressing that entire person,
the whole person.
First, paying attention to sleephygiene is critical.
Regular sleep helps regulatemood and energy levels.
(40:03):
Sticking to a consistent sleep schedule,
creating a calm bedtimeroutine and minimizing screens
and caffeine in the eveningcan all promote better rest
and reduce the risk of mood episodes.
Diet and nutrition are also key components
of lifestyle management.
A balanced diet rich inwhole foods like fruits
(40:26):
and vegetables, lean proteins
and whole grains provideessential nutrients
that support brain health.
Avoiding excessive sugar, caffeine,
and processed foods canhelp minimize energy spikes
and mood fluctuations.
Creating a more stablefoundation for daily life.
(40:46):
Physical activity is another vital piece.
Regular exercise doesn'tjust support physical health.
It also releases endorphinsthat boost mood, reduce anxiety
and improve sleep quality.
It doesn't have to be intense.
Even daily walks, yoga
or light strength training can make a
(41:07):
significant difference.
Establishing routines inthese areas, in sleep, diet
and exercise can help adults
with bipolar disorder createmore stability in their lives,
supporting overall wellness
and helping prevent extreme mood shifts.
Thanks for coveringthose lifestyle factors, Lisa.
(41:28):
Can you tell us moreabout the evidence-based
psychotherapy approachesthat are especially effective
for managing bipolar disorder?
Of course, Brayden,
and that's actually avery important component
that we really need to to consider
'cause evidence-based psychotherapyapproaches are crucial
for managing bipolar disorder effectively.
(41:50):
Each therapy addresses uniqueaspects of the condition,
helping patients gainbetter control over symptoms
and achieves stabilityjust beyond medications
and lifestyle changes.
First, we have psychoeducation.
This approach is allabout empowering patients
(42:10):
by providing detailedknowledge about bipolar itself.
Arguably, it's probablynot a psychotherapy,
but still critical to do this.
For every patient thathas bipolar disorder,
the primary goal with psychoeducation is
to build a solid rationale for seeking
(42:30):
and sticking with treatment.
By understanding the natureof their symptoms, the purpose
of the medications
and the potential side effects,
patients will feel more empowered
to handle stressful situations
and stay adherent to their treatment plan.
The focus here is on creatinga partnership in which
(42:51):
patients feel informed and and control.
So cognitive behavioral therapyis very common in bipolar
disorder as a psychotherapy modality.
This therapy works on theidea that thoughts, feelings,
and behaviors are interconnected
and influence one another,especially during mood episodes.
(43:13):
The main objective here isto help patients recognize
and change their thoughts, beliefs,
and behaviors that can triggeror worsen their symptoms.
Cognitive behavioral therapystrategies include helping
patients understand their condition,
develop practical copingskills, improve sleep routines,
(43:34):
and strengthen adherence to treatment.
It is a comprehensive approach
that offers concrete strategies
for managing symptoms day to day.
Another effective therapyis family focused therapy.
The foundation of thistherapy is that unsupportive
or negative family dynamicscan increase the patient's
(43:54):
stress and risk for mood episodes.
Family focused therapy aimsto reduce overall stress
by improving and support within the family
or primary relationships.
It emphasizes the importance
of understanding bipolar disorder,
including the stress vulnerability model
and medication adherence.
(44:16):
Concrete communication strategiessuch as active listening
and positive requests are taught
to foster a more supportive environment,
and you will often seefamily-focused therapy used more
frequently in adolescents
or children with pediatricbipolar disorder.
Lastly, interpersonal
(44:37):
and social rhythm therapyfocuses on creating stability in
daily routines and social interactions.
This therapy is based on the understanding
that irregular routines candisrupt circadian rhythms
triggering or worsening mood episodes.
The goal of interpersonal
and social rhythm therapyis to stabilize both mood
(45:00):
and circadian rhythms byaddressing interpersonal issues
and establishing regular daily habits.
Key strategies includelinking mood changes
with life events, grievingthe loss of a healthy self,
resolving primary interpersonal issues,
and maintaining consistent social rhythms.
(45:20):
Interpersonal social rhythmstherapy is probably the most
common psychotherapy modalityused in bipolar disorder
because it has a very strong evidence base
with its efficacy.
Each of these therapiesthough offer patients a very
structured approach tomanaging bipolar disorder
by targeting very specific symptoms
(45:42):
and their life areas that are problematic.
By incorporating a combination
of these evidence-based modalities,
we can help patientsachieve a more comprehensive
and resilient treatment plan.
Thanks for breaking downthose psychotherapy approaches.
Lisa, it can be helpful tocollaborate with therapists,
counselors, and othermental health professionals.
(46:05):
Do you have any insightabout collaboration
with primary care orother specialty providers?
Actually, yes Brayden. Collaboration
between primary care providers
and psychiatric mentalhealth nurse practitioners
or any other psychiatricclinician is actually essential
for managing bipolar disorder, especially
(46:27):
because of the high ratesof medical comorbidities
that often accompany the condition.
So patients with bipolardisorder are at an increased risk
for issues like cardiovasculardisease, diabetes,
and obesity, partly dueto the illness itself,
but also as a result of thepsychopharmacological treatments
(46:49):
that we implement.
Many of the medicationsused to stabilize mood such
as anti-psychotics
and mood stabilizerscan lead to weight gain,
metabolic syndrome,
and other side effects
that require careful medical oversight.
So it is very important
for the psychiatric mentalhealth nurse practitioner
(47:10):
to work closely with ourprimary care colleagues
that can help us monitorthose physical health risks
alongside mental health needs, ensuring
that patients receiveintegrated and holistic care.
This collaboration doesn'tjust address the symptoms
of bipolar disorder,
but it promotes overallhealth leading towards better
(47:32):
outcome and quality oflife for these patients.
Really valuable information.Thank you for sharing.
This has been such a great discussion, Brayden.
I think we have covered a lot
of important ground fromunderstanding the complexities
of the diagnosis to exploringboth pharmacological
and non-pharmacological treatments
(47:53):
that truly support patientswith bipolar disorder.
Yeah, it's so important
and so valuable to look atbipolar disorder from all angles,
especially since managing iteffectively really does require
a well-rounded, individualized approach.
I hope our listeners feelmore equipped with insights
(48:14):
that they can use andimplement into their practice.
Yes, and just remembering
that each patient's journey is unique
and may need a mix of treatments,whether it be medication,
psychotherapy,
or lifestyle management, itcan make a big difference.
Thank you for sharing yourexpertise on pharmacological
(48:35):
interventions, Brayden.
Yeah, thank you, Lisa,
for all your insights into the therapeutic
and lifestyle interventions.
It's been a pleasure workingthrough this with you.
And for our listeners,thank you for tuning in.
We hope that this discussion supports you
in providing compassionateinformed care to those
with bipolar disorder.
(48:55):
Definitely stay curious, keep learning,
and thank you for joining us.
Lisa, Brayden,
Thank you for this excellent podcast.
To our listeners, thankyou for visiting NP Pulse.
This program and the accompanyingclinical resource tool
were made possible by amedical education grant from
Alkermes Incorporated.
(49:17):
Continuing education creditfor this program may be claimed
through November 30th, 2025. Toclaim credit for the program,
login to CE Center at
aanp.org/cecenter,
search for this program byname and complete the post-test
and evaluation by enteringthe participation code
(49:39):
BIPOLAR24.
As always, thank you for theexcellent work you do every day
to take care of patients.
Your feedback is truly important to us.
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