14.2 Nutrition and Chronic Pulmonary Illnesses

Mood stabilizers are crucial in managing bipolar disorder, with lithium as the gold standard. These medications work by modulating neurotransmitters, offering neuroprotection, and regulating mood. They prevent manic and depressive episodes, reducing the frequency and severity of mood swings.

Lithium and anticonvulsants like valproic acid, carbamazepine, and lamotrigine are the main mood stabilizers. Each has unique effects and side effects, requiring careful monitoring and patient education. Nurses play a vital role in assessing, monitoring, and educating patients on these medications.

Mood Stabilizers

Key features of mood stabilizers

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• Lithium serves as the gold standard treatment for bipolar disorder by reducing frequency and severity of manic and depressive episodes through modulation of neurotransmitter systems (serotonin, dopamine, and glutamate), neuroprotective effects via increased brain-derived neurotrophic factor (BDNF), and inhibition of glycogen synthase kinase-3 (GSK-3) which regulates mood and neuroplasticity
• Anticonvulsants (valproic acid, carbamazepine, lamotrigine) are used as alternatives or adjuncts to lithium
  • Valproic acid and carbamazepine enhance GABA neurotransmission leading to mood stabilization and reduce neuronal excitability while modulating dopamine and serotonin systems
  • Lamotrigine blocks voltage-gated sodium channels stabilizing neuronal membranes and reduces glutamate release contributing to mood stabilization

Effects of lithium and anticonvulsants

• Lithium prevents manic and depressive episodes, reduces suicide risk, but has side effects including nausea, diarrhea, tremor, weight gain, hypothyroidism, nephrogenic diabetes insipidus, and a narrow therapeutic index requiring regular serum level monitoring
  • Drug interactions with NSAIDs, ACE inhibitors, and thiazide diuretics can increase lithium levels
• Valproic acid reduces manic episodes and rapid cycling but may cause nausea, vomiting, weight gain, hepatotoxicity, pancreatitis, teratogenicity, and interacts with aspirin, warfarin, and other anticonvulsants
• Carbamazepine reduces manic episodes and rapid cycling with side effects of dizziness, drowsiness, nausea, liver enzyme induction, agranulocytosis, and interactions with oral contraceptives, warfarin, and other anticonvulsants
• Lamotrigine prevents depressive episodes and rapid cycling but may lead to dizziness, drowsiness, headache, rash (including rare but serious Stevens-Johnson syndrome), and interacts with valproic acid, carbamazepine, and oral contraceptives

Pharmacokinetics and Safety Considerations

• Therapeutic index is crucial for mood stabilizers, especially lithium, as the difference between therapeutic and toxic doses is narrow
• Pharmacokinetics of mood stabilizers influence dosing schedules and potential for drug-drug interactions
• Mood episodes can affect medication adherence and alter drug metabolism
• Long-term use of some mood stabilizers may lead to neurotoxicity, requiring careful monitoring
• Drug-drug interactions can significantly impact mood stabilizer efficacy and safety

Nursing care for mood stabilizer patients

• Assessment involves evaluating mental status, mood, behavior, medication adherence, side effects, serum drug levels (lithium, valproic acid), renal and thyroid function (lithium), liver function (valproic acid, carbamazepine), and hematologic parameters (carbamazepine, lamotrigine)
• Monitoring includes regular serum drug level measurements (lithium, valproic acid), periodic renal, thyroid, liver, and hematologic function tests, mood, behavior, treatment response, and emergence of side effects or adverse reactions
• Interventions involve administering medications as prescribed, educating patients and families about medication use, side effects, and importance of adherence, encouraging healthy lifestyle habits (regular sleep, exercise, stress management), collaborating with mental health professionals for comprehensive care, and adjusting medication dosages or switching medications as needed based on clinical response and side effects

Patient education for mood stabilizers

• Emphasize the importance of medication adherence for preventing relapses and maintaining stability
• Inform patients about common side effects and encourage reporting of severe or persistent side effects to healthcare providers
• Stress the significance of regular blood tests and monitoring for safety and dose adjustments
• Advise patients to avoid abrupt discontinuation of mood stabilizers as this can lead to relapse or withdrawal symptoms
• Educate about potential drug interactions and the need to inform all healthcare providers about mood stabilizer use
• Highlight the importance of a healthy lifestyle including regular sleep, exercise, and stress reduction techniques
• Encourage open communication with healthcare providers and support systems about mood changes and treatment concerns
• Provide resources for additional support such as therapy, support groups, and crisis hotlines