NUR 7632 Module 3 Bipolar I Mania Case: Antimanic Choice, Lithium and Relapse Prevention Example

Four Nights Without Sleep and a Plan to Buy a Theater: Treating First-Episode Mania and Choosing Lithium for the Years After

Student Name

M.S. in Nursing, Psychiatric Mental Health Nurse Practitioner, Thomas Edison State University

NUR-7632: Advanced Assessment, Differential Diagnosis, and Management of Psychiatric Disorders: Adult Population, Part A

Mentor Name

Month Day, Year

Four Nights Without Sleep and a Plan to Buy a Theater: Treating First-Episode Mania and Choosing Lithium for the Years After

Brought In by His Sister

Ethan, an invented patient, is 27 and in the second year of a doctoral program in Princeton. His sister brought him to the emergency department after he called her at 4 a.m. for the third night running to describe a plan to turn an old theater into a research institute. He has slept perhaps two hours in four nights, says he feels better than ever, talks rapidly and jumps from topic to topic, and has put a 15,000 dollar deposit on the building. He became angry when security asked him to wait. He believes he has been chosen to solve climate change but does not hear voices.

A year ago he had two months of depression after his father's death, treated by his primary care clinician with sertraline, which he stopped in the spring. He drinks socially and denies stimulants; a urine drug screen is negative. His thyroid tests, blood count, metabolic panel and kidney function are normal. His paternal aunt was treated with lithium for many years.

On arrival he refuses admission, saying nothing is wrong. He is not threatening anyone, but he has not eaten properly in days, has driven at high speed to the theater twice and has emptied an account that held his rent. The team judges that his judgment is too impaired to care for himself safely, and after a long conversation in which his sister takes part, he agrees to a voluntary stay. The paper notes the state's standards for involuntary commitment and why they were not needed once he agreed.

The Diagnosis

Ethan's elevated and irritable mood, reduced need for sleep, pressured speech, racing thoughts, grandiosity and risky spending have lasted more than a week and have led to hospital care, which meets the criteria for a manic episode and therefore bipolar I disorder. The prior depression, now seen in light of the mania, fits the same illness. His negative drug screen, normal thyroid tests and lack of new medicines rule out the common secondary causes. His grandiose belief is held with conviction and counts as a psychotic feature.

Acute Treatment

Cipriani et al. (2011) compared 13 drugs across 68 randomized trials with 16,073 adults in acute mania, using both direct and indirect comparisons. Haloperidol, risperidone, olanzapine, lithium, quetiapine, aripiprazole, carbamazepine, asenapine, valproate and ziprasidone all reduced mania more than placebo, while gabapentin, lamotrigine and topiramate did not. Antipsychotics as a group worked better than mood stabilizers in the short term, with risperidone, olanzapine and haloperidol among the strongest, and the authors noted that olanzapine, risperidone and quetiapine had a good balance of effect and acceptability.

On the unit, Ethan begins risperidone at a low dose, raised over several days, which treats both the mania and his grandiose belief. A short course of lorazepam helps sleep and agitation in the first nights. The unit's quiet room, limited visitors and fixed sleep times reduce stimulation.

Why Lithium for the Long Term

Mania often returns, and the choice of maintenance treatment matters more over the years than the acute medicine. The BALANCE trial randomly assigned 330 people with bipolar I disorder to lithium, valproate or both for up to two years (BALANCE Investigators and Collaborators, 2010). Both the combination and lithium alone prevented relapse better than valproate alone, and the trial did not find that adding valproate to lithium clearly improved on lithium by itself.

Cipriani et al. (2013) reviewed 48 randomized trials with 6,674 participants comparing lithium with placebo or other drugs in long-term treatment of mood disorders. Suicides were far fewer on lithium than on placebo, an odds ratio of just 0.13, and deaths from all causes fell too. The authors suggested lithium may lower suicide partly by preventing relapse and partly by reducing aggression and impulsivity. With his aunt's good response, these findings support lithium for Ethan.

Starting Lithium Safely

Before lithium begins, his kidney function, thyroid tests, calcium, weight and an electrocardiogram are on file. Lithium starts at a low dose and the blood level is checked five days later, twelve hours after the evening dose, aiming for the maintenance range. Ethan and his sister learn the signs of toxicity, such as coarse tremor, vomiting, diarrhea, unsteadiness and confusion, and why dehydration, ibuprofen and some blood pressure medicines raise levels. Levels are checked again after each dose change, then every three to six months, with kidney and thyroid tests every six to twelve months.

Once his mania settles, the risperidone is tapered over the following months if lithium alone keeps him stable, to limit weight gain and other effects.

Life After Discharge

Ethan's recovery depends on more than the prescription. He and his sister learn to recognize his early warning signs, such as sleeping less than six hours and starting new projects late at night. A regular sleep schedule is treated as part of treatment. He is referred to a group program for people with bipolar disorder, and his university's disability office is contacted, with consent, to arrange a reduced course load next term. His sister helps him cancel the theater deposit, and he agrees that she will hold his credit card for the first month.

Money and studies are protected while he recovers. With his consent, his sister holds his credit cards for the first months and the theater deposit is disputed with the seller, citing his illness at the time of signing. His advisor hears only that he is on medical leave, and a return plan reduces his teaching load for the first term back. These practical steps matter because the losses of a manic episode, in money and in standing, often drive the depression that follows.

Conclusion

Ethan's first manic episode, with grandiose belief and risky spending, confirms bipolar I disorder. Risperidone, supported by the antimanic comparison, treats the acute phase, and lithium, supported by BALANCE and the suicide review, is the long-term choice. Careful lithium monitoring, early warning signs and practical steps to protect his money and studies complete a plan meant for the years ahead, not only this admission.

References

BALANCE Investigators and Collaborators. (2010). Lithium plus valproate combination therapy versus monotherapy for relapse prevention in bipolar I disorder (BALANCE): A randomised open-label trial. The Lancet, 375(9712), 385-395. https://doi.org/10.1016/S0140-6736(09)61828-6

Cipriani, A., Barbui, C., Salanti, G., Rendell, J., Brown, R., Stockton, S., Purgato, M., Spineli, L. M., Goodwin, G. M., & Geddes, J. R. (2011). Comparative efficacy and acceptability of antimanic drugs in acute mania: A multiple-treatments meta-analysis. The Lancet, 378(9799), 1306-1315. https://doi.org/10.1016/S0140-6736(11)60873-8

Cipriani, A., Hawton, K., Stockton, S., & Geddes, J. R. (2013). Lithium in the prevention of suicide in mood disorders: Updated systematic review and meta-analysis. BMJ, 346, Article f3646. https://doi.org/10.1136/bmj.f3646