Discuss the nursing care you would deliver to a twenty five year old woman recently diagnosed with bi-polar disorder.
In this essay the writer will discuss the diagnostic criteria for bi-polar disorder, the bio psychosocial implications of the diagnosis and the core principles underpinning recovery. This essay will also discuss the signs and symptoms of bi-polar and the nursing process afforded to service users who receive a bi-polar diagnosis. The World Health Organisation (WHO, 2001 p1) defines mental health as “a state of well-being in which every individual realises his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community”. However, service users who engage with the mental health services are not always able to fill these roles. Bipolar disorder is a leading cause of disability worldwide (Merikangas et al., 2011). The DSM 5 (2013 p123) outlines the diagnostic criteria for a “diagnosis of bipolar I disorder, it is necessary to meet the criteria for a manic episode. The manic episode may have been preceded by and may be followed by hypomanic or major depressive episodes”. For bipolar II disorder diagnostic criteria, the service user must have at least one hypomanic episode and at least one major depressive episode. Bi-polar affective disorder is the occurrence of manic episodes in addition to depressive episodes. Diagnosis of bi-polar disorder usually involves the occurrence of two major mood episodes, usually one depression and one mania. Bi-polar disorder can be rapid cycling and can consist of four or more mood episodes during the previous twelve months and can be characterised by rapid cycling. The clinical features of bi-polar can be psychological, physical or social.
The aetiology of bi-polar is linked to genetics and family studies show that the risk of developing a mood disorder are greater in biological relatives of service users than in the general population. It is also true that mania/bipolar disorder is associated with the cyclothymic personality type. This personality type is prone to mood swings and displays a tendency towards extremes of mood. An excess of the neurotransmitters serotonin and noradrenaline is thought to have some role in the cause of mania. Clinical features of mania (psychological) are elevated mood, flight of ideas, pressure of speech, inflated self-esteem, lack of judgement, poor concentration and attention span, distractibility, irritability, over-optimism, perceptual disorders (appreciation of colours as especially vivid) and psychotic features, particularly delusions of grandeur. Clinical features of mania (physical) are increased energy, hyperactivity, undertaking too many activities, hyper sexuality, decreased appetite, decreased need for sleep and lack of attention to personal hygiene. Clinical features of mania (social) are interfering behaviour, social disinhibition, overfamiliarity, extravagant spending, inappropriate and marked impairment of social functioning. A study performed by Inder et al (2010) has identified that bipolar disorder creates experiences of confusion, contradiction and self-doubt as a consequence of the fluctuating mood states. The conflicting side of a manic episode is depression and the presentations are contrasting. The ICD 10 (2013) outlines the classifications of depression as mild depressive episode, moderate depressive episode, severe depressive episode without psychotic symptoms and severe depressive episode with psychotic symptoms. Depression is an affective disorder and characterised as a disorder of mood with traits that are more intense and persistent that normal unhappiness. Aware (2013) showed that approximately 300,000 people thought to be suffering from depression in Ireland. Alarmingly this translates to about 10,000 admissions to psychiatric hospitals for depression each year. The WHO predict that by the year 2020, depression will be the second highest cause of the global disease burden. It is thought that 8-12% of men and 18-25% of women will suffer a major depression in their lifetime (WHO, 2013). Causes of depression are vast and vary from service user to service user. However, the common bases are genetics, biochemical causes, early environment, stressful life events, social factors and physical illness. Genetic research by Livingston (2006) has shown that parents, children and siblings of severely depressed service users have a higher risk of depression. They are up to three times more likely to develop depression if a parent or sibling has severe depression. Studies on identical twins show that if one has depression then the other twin will have depression in 76% of the cases, (Cohen-Woods. S. et al 2013). When these twins are raised apart, the other twin will have depression in about 65% of the cases. Therefore, this suggests a strong genetic influence. Studies of non-identical twins show that if one has depression, the other has depression about 20% of the time. Adoption studies revealed that incidence of depression is higher in a child born to a parent with depression but reared by parents with no history of depression. What is inherited is not depression itself but a vulnerability to depression. This means that someone who has inherited a vulnerability to depression, and suffers some significant stressful event, may develop depression. However, it is important to point out, depression may also occur in those who have no family history of depression. Biochemical factors for depression may stem from a low level of neurotransmitters in the brain, particularly serotonin and noradrenaline. The use of antidepressants which increase the levels of neurotransmitters brings about a reduction in depressive symptoms. SSRI medications are typically used as mood stabilisers have become central in maintaining a service user’s wellbeing. Early environment is seen as pivotal factor in service users who get a diagnosis of depression and bi-polar. Maternal deprivation may predispose to depressive disorders in later life (particularly separation from a parent before the age of 11). Many people who are depressed often have experienced traumatic events or deep unhappiness during childhood. Stressful life events also generate the onset of depression. Recent life events can have a triggering effect on depression. These include bereavement, loss of a job, marital or relationship breakdown, severe stress, social factors – for instance, those in lower socio-economic groups are more likely to suffer from depression, poor social support including lack of intimacy and poor social integration, lack of sense of belonging and lack of someone to confide in. Similar to mania, the symptoms of depression can be broken down into three main types, psychological symptoms, physical symptoms and social symptoms. The psychological symptoms manifest as depressed mood for at least two weeks and the signs and symptoms include anhedonia, apathy, avolition, feelings of worthlessness, hopelessness, guilt, despair, profound sadness for others, inability to think, concentrate or make decisions, decreased self-esteem, over-reaction to minor mistakes, suicidal thoughts or suicidal ideation and possible psychotic features (for example delusions). The physical symptoms can include change in appetite usually leading to weight loss or gain, sleep disturbance which can be either early morning wakening or difficulty getting to sleep or hypersomnia, tiredness, decreased energy, decreased activity level, slowed motor activity with slower movements, less gesticulating when talking, slower speech that can also become monosyllabic and monotone, decreased bowel activity, decreased libido and decreased sexual activity, poor physical appearance, unkempt, unwashed or dishevelled and finally there be possible agitation like hand wringing or picking at clothes. Social symptoms will normally involve isolation or avoidance of friends, family or large gatherings, difficulty communicating, dysfunctional interpersonal skills, excessive reassurance seeking and loss of interest in college or work thus leading to possible expulsion from college and employment.
Bi-polar disorder is a lifelong and disabling condition and its course is highly variable. Nurses can make a positive contribution through psycho-education, relapse prevention, physical care, recovery planning and by developing knowledge of this condition. The correct assessment, planning, implementation and evaluation is crucial in the treatment and recovery of service users with bi-polar disorder. Person-centred care is the overriding context and this includes collaboration with the patient’s family (Dore G, Romans S E 2001). Families are challenged when they witness a loved one who is acutely ill with depression or mania. Manic service users can be irritable and fragile and may angrily respond to efforts to curb their reckless behaviour. Depressed service users may be agitated and unable to carry out their normal social functions. Family members can be real experts when it comes to recognising signs and symptoms and this expertise should be regarded with respect. All concerns should be taken seriously. Young females coming into the mental health services will have lots of concerns and questions they will require answers to. At 25 years old the priorities could include starting a family, work, education, financial support, friendships or housing. At such a young age with a long life ahead, they may not see a light at the end of the tunnel. This is where health care professionals provide the correct support, education and guidance to direct the service user and equip them with the tools to overcome and manage their condition. Service users may be very embarrassed about some of the things they have done while manic, so, as always, a sensitive approach should be taken. Female service users may become worried about medications and the effects on weight gain or loss. These concerns are very real and education on exercise and diet are vital to their recovery. Education should include general health promotion and advice around avoiding challenging and stressful circumstances where possible. Relapse prevention planning involves the recognition of early warning signs, family members can be particularly helpful here. These early signs, for example, increased energy and an elated mood may indicate the need for an intervention like anti-manic medication. NICE (2009) guidance around depression can be followed but the use of anti-depressants should be cautious if the service user has had previous episodes of mania. Mania is treated with anti-psychotic drugs such as olanzapine. Mood stabilising drugs such as lithium may be used. Particular caution needs to be taken with women of child-bearing age given the risk of foetal damage. In very severe cases, where other methods have not worked, electroconvulsive therapy may be used.
It’s important to plan for discharge when a service user comes into the care of the mental health team and this is when the recovery should also commence. A Vision for Change (2006 p 4) states that “The emphasis is firmly on recovery and on facilitating active partnerships between service users, carers and mental health professionals. Its recommendations are innovative and some of them are challenging”. Recovery in other health contexts is understood to mean getting back to the way you were before illness or accident affected you, or getting back to normal. While we know that people with long term mental health problems can and do recover in this sense, recovery describes a broader, more holistic interpretation of the word. Anthony (1993) describes recovery as “a way of living a satisfying, hopeful, and contributing life even with limitations caused by the illness. Recovery involves the development of new meaning and purpose in one’s life as one grows beyond the catastrophic effects of mental illness. Recovery from mental illness involves much more than recovery from the illness itself”. There are several support groups that assist both the service user and their families following discharge. Groups such as Shine, Mindfreedom, Aware or Jigsaw provide information, therapeutic and focused recovery programmes for service users in the community. Having optimism and hope about their recovery and for the future along with valuing the person’s voice and personal meaning are some of the ways towards a successful recovery. It is also essential to mobilise the service users own resources and understand their strengths and weaknesses. Locally, in Mayo we have the Rehab and Recovery teams and the Recovery College that provide excellent support and back up for those who need further services upon coming into the mental health services. Doctors play a vital role in the course of a service users recovery, the family GP and the psychiatrist are pivotal in the recovery process. The psychiatrist will monitor the mental health state and prescribe medications while the GP assesses the overall health and treats co-morbid conditions such as diabetes, heart disease, high blood pressure and high cholesterol to name but a few. Alas all the recovery programmes and medical interventions cannot succeed without the collaborate work of the service user themselves and early intervention is crucial in prevention of relapse or further admissions to acute units.
The consequences of bi-polar disorder can have a devastating effect, the cycles of depression and mania can result in a service user becoming detached from family, friends and society due to its presentations and could possibly lead them to a life of solitude without the right interventions. As heath care professionals and in accordance with the code of professional conduct for nurses and midwives (2014), it is essential to provide support and education to all service users in order that they continue in the maintenance of their mental health needs and provide competent and practical information to them and their families in times of crisis. We must become an advocate for those who cannot speak out for themselves and always remember that the service user is the most important person in any decision making.
