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Bipolar disorder (BO) is a complex and challenging brain disorder, in which moods range back and forth between sadness to euphoria. Widely recognized as a mental health entity, BO presents with a variety of symptoms: physical and emotional. The symptoms vary in duration and depth, and often resemble physiological possibilities. Bipolar disorder challenges patients, families and professional caregivers for many reasons, not the least of which is obtaining an accurate diagnosis. Patience is essential as pharmacological treatment(s) are explored and refined. Psychosocial therapies offer support and strategies for coping with ongoing lifestyle interruptions and annoyances. Relapse and recurrence is common.
Bipolar disorder patients access the healthcare system in numerous ways. Consequently, nurses in any setting are likely to encounter a patient with a diagnosis of bipolar disorder, or a patient who has yet to receive the diagnosis of bipolar disorder. As comorbidities are often present in persons with bipolar disorder, it is even more likely that a nurse’s practice will encounter a bipolar disorder patient with heart disease, diabetes, substance use, suicidal thoughts, or acute psychosis.
This independent study describes bipolar disorder: scope, risk factors and symptoms, types of bipolar disorder, treatment options, and implications for nursing care along the lifespan. Communication and coordination throughout the continuum of care among the disciplines, along with an understanding and trusting nurse-patient relationship contributes to care excellence.
Bipolar Disorder (BD)
Previously known as manic-depression, bipolar disorder is a chronic, persistent and complex illness which causes episodic changes in a person’s mood, energy levels, behaviors and thinking. While the Greeks and Romans used the terms melancholia and mania, the first published description of “la folie circulaire” (circular insanity) was by Jean-Pierre Falret in 1851 with melancholia (depression) and mania as the key features (Krans, B. & Cherney, K., 2016). Known for years as a mental or mood disorder, BD is recognized as a brain disorder (American Psychiatric Association, 2015; NIMH, 2016). The recognition and acknowledgment of the brain-body-mind relationship underscores the interconnectedness of cause, treatment and response.
The age of diagnosis ranges from 18-60+ years. The average age of onset is 25 years. Unlike incidence which measures new case, lifetime prevalence describes the proportion or percentage of the population who has ever had a diagnosis of bipolar disorder. For the age demographic, the lifetime prevalence is as follows: 5.9% (18-29 years); 4.5% (30-44 years); 3.5% (45-59 years) and 1% (60+ years). The 12-month prevalence accounts for about 2.6% of the adult population; of these nearly 83% of cases in the adult US population are considered “severe” (nimh.nih.gov). Data by sex and race are not reported. Some data suggest that females are at greater risk for depression and rapid mood shift while males have a greater risk for mania. Debate continues about diagnostic criteria for children; prevalence data for children are not available. For statistical information about bipolar disorder in adults and children check out www.nimh.nih.gov/health/statistics/biopolar-disorder
Multiple risk factors are believed to contribute to the development of bipolar disorder. No single etiology of BD has been identified. The National Institute of Mental Health describes bipolar disorder in adults possibly due to genetics, or brain variations in structure or function. A genetic etiology is being studied as there is evidence of familial tendencies.
Yet, in identical twins, bipolar disorder may be present in one twin and not the other twin. Stressful life events may also contribute to the development of BD. The impact of childhood adverse events and misdiagnoses across the lifespan – such as major depression postpartum depression attention deficit hyperactivity disorder (ADHD) and various anxieties – are also potentially undiagnosed cases of bipolar disorder.
Recognition and Diagnosis of Bipolar Disorder
As a chronic and complex disorder with relapses and recurrences, initial diagnoses may be inaccurate because patients tend to seek treatment when depressed not manic. Physical health problems – such as diabetes, heart or thyroid disease, alcohol and substance use – may also prompt the patient to seek health care. Nonadherence to medication therapy results in relapses. Office visits, community clinics, and emergency departments are among the many locations used to access the health care system. All nurses, especially in non-psychiatric practice settings, are important to the recognition and subsequent care of patients with bipolar disorder.
An accurate diagnosis of bipolar disorder is essential to development of an effective plan of treatment.
- Complete physical exam to eliminate other diseases causing mood
- A comprehensive medical history considering family and socially influenced behaviors that might be contributing to changes in
- Screening for depression to differentiate unipolar (clinical depression or major depressive disorder) from bipolar depression (occurring with mania or hypomania).
Types and Symptoms of Bipolar Disorder
According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), bipolar disorder is a brain disorder with mood changes (APA, 2013). This independent study focuses on Bipolar I Disorder (BID) and Bipolar II Disorder (BIID).
Bipolar I Disorder (BID)
Bipolar I Disorder is characterized by mood swings and patients experience one or more episodes of full mania. Mania is intense and may last for at least a week. Episodes of depression are also present and may last for up to two weeks. Most patients have both episodes of mania and depression. It is rare that BID patients only experience mania.
Depression typically prompts people to seek treatment. With unipolar depression such as when a person feels ‘sad’ or ‘down’ because of a situation or series of stressors, depression in bipolar disorder significantly impacts a person’s ability to function. Emotionally, patients may be despondent and display a lack interest in family, friends, school, and/or work. Previous enjoyments hold no interest or enthusiasm.
Feelings of anxiety or an inability to concentrate, agitation, irritability and guilt are common. Further, they may express feelings of worthlessness and wonder if things will ever improve. Recurrent thoughts of death may prompt suicide contemplation or attempts. If clinical depression worsens and is untreated, patients may be unable to meet basic needs unassisted. Offers to help or provide assistance may prompt irritable responses to the concerns of loved ones and health care providers. Other causes of depression related to postpartum or a personal loss should also be considered.
Mania is the “high” side of bipolar 1 disorder. Patients experiencing full mania, or hypomania, rarely seek out treatment on their own. In a manic or hypomanic phase, people believe they are just fine and often consider those trying to assist them as hostile, or misguided.
During mania, the patient’s mood is elevated and expansive; irritability is common. They feel great about themselves and hold grand ideas for accomplishments. They may dart from idea to idea, be easily distracted and start multiple projects which are not completed. As energy levels rise in the manic phase, sleeping, eating and drinking are also interrupted. Speech is rapid and pressured; attempts to interrupt or redirect are difficult. While in the manic phase, patients appear euphoric and happy. Judgment and insight are impaired. Risky behaviors associated with excessive drug use, speeding, gambling, spending sprees and acting out sexually may have long term negative consequences resulting in shame and guilt.
Psychosis in persons with bipolar I disorder may develop during episodes of severe depression or mania. Delusions (false beliefs) and hallucinations (auditory or visual) are reported and usually correspond to the patient’s mood. When depressed, delusions and hallucinations are consistent with despondency. The patient may not eat because they feel worthless, imagine that they’ve done something evil, or hear a voice that says the world has ended. If manic, themes tend to be more paranoid or grandiose. There may be a fear that someone will steal their belongings or money, or that God is speaking to them as them as a special messenger. With psychosis, a diagnosis of schizophrenia is also possible.
Bipolar II Disorder (BIID)
Bipolar II Disorder is characterized by episodes of hypomania and depression. Hypomania is less intense than full mania. BIID patients experience at least one depression episode and episodes of hypomania, but never a full manic episode. Correct diagnosis of BIID is complex process, necessitates careful evaluation of mood states, and a patient-caregiver partnership. To avoid misdiagnosis when a patient presents with depression symptoms, it is important to evaluate if there have been any past periods of hypomania or mania which can suggest this is bipolar disorder.
Hypomania also has negative impacts on the person’s life. As the hypomanic patient experiences an intoxicating sense of well-being, they may decide to stop medications or not participate in psychosocial treatments. At this point, they believe that they do not have bipolar disorder and/or other physical conditions. Hypomania can also progress into either a full manic or depressive episode. Repercussions of mania or hypomania can be as devastating as the episodes of depression for patients and their significant others.
Other Bipolar Disorders
Frequent and recurring periods of hypomania and depression lasting over a period of two years, one year in children, characterizes cyclothymic disorder or cyclothymia. Previously known as ‘rapid cycling bipolar disorder,’ the name change was made with the DSM-5 (APA, 2013). In the other unspecified and specified disorders, patients do not have symptoms that would meet criteria for BID, BIID, or cyclothymic disorder. The diagnostic category of mixed episode was changed to mixed features in the DSM-5 (APA, 2013). With a mixed features category, moods shift rapidly between mania and depression with variations in intensity and duration. This diagnostic category was established to assist with the specificity of treatment and diagnosis. After an initial diagnosis, nurses and the treatment team are just beginning a plan of care to achieve mood stability and effective outcomes.
The variability of symptoms and manifestations of bipolar disorder challenges clinicians, the patient and family members. Key points to remember include:
- Changes in mood – often sadness or depression to some extent – accompany many chronic health problems, or the challenges of Some neurological disorders, living with COPD, CHF or limitations in mobility or cognitive function also can impact mood and result in depression.
- Endocrine disorders such as hyperthyroidism may affect moods or result in hyperactivity, with an inability to concentrate, or stay Hypothyroidism results in loss of interest in personal care and relationships and a tendency to avoid usual enjoyments.
- Mood swings may stabilize with medications, so patients ‘feel good,’ think they are well, and stop taking their Other patients may not like one or more of the side effects, and stop taking their meds. Adherence to prescribed medications is a major challenge to an effective treatment plan for patients with bipolar disorder.
- Medication prescribed for mood stabilization, treatment of depression and others have side effects. Pharmacological advances have lessened the frequency of tardive dyskinesia and extrapyramidal symptoms present in typical The atypical antipsychotics present fewer problems, but may result in tremors, restlessness and muscle rigidity.
Treatment for Bipolar Disorder
Medications and psychosocial therapies are prescribed for bipolar disorders. As with many chronic health problems, bipolar disorder patients need to take medications and learn to make life style adjustments. Managing symptoms, finding and adhering to prescribed medications and participating in psychosocial therapies assist the patient to stabilize and enhance quality of life. Psychosocial therapies include Psychoeducational Therapy (PE), Interpersonal Social Rhythm Therapy (ISRT), Cognitive Behavioral Therapy (CBT), and Family-Focused Therapy (FFT). Integrated care involving case managers in support of medication adherence and selected psychosocial therapies is providing additional support for the patient with bipolar disorder.
Medications are prescribed to prevent acute episodes of depression or mania and to stabilize mood variability. With a diagnosis of bipolar disorder, medication becomes a critical part of his/her treatment regimen. Medication management is complex and can be a frustrating process for the patient and his or her health care professionals.
Unfortunately, there is no single combination of medications which works well for everyone. The right combination to manage a specific patient’s mood instability takes time and can change over time.
Frustration and feelings of futility may ensue. Jann (2014) reported that more than 75% of the patients take the prescribed medications less than 75% of the time.
Polypharmacy, drug-drug interactions, lack of adherence and side effects necessitate that nurses appreciate some nuances of medications used to treat bipolar disorders. This article provides a limited overview of medication management options. Prescription guidelines vary depending on the source and date of publication. Research on the efficacy, quality of life and cost of medication therapy is of world-wide interest. Baseline lab work is needed prior to medication therapy for newly diagnosed patients. For long term use, on-going monitoring is also indicated.
Three categories of medications are used to treat bipolar disorder: mood stabil izers, antipsychotics including atypical antipsychotics, and antidepressants. The search for a combination of medications requires patience. For the patient, side effects or a feeling of being cured contributes to nonadherence. A variety of blood tests may be indicated to identify negative consequences (Cullison & Resch, 2014). On-going monitoring to evaluate response to medication therapy is essential. Changes to the prescribed regimen are to be expected.
Lithium and anticonvulsants stabilize mood swings of mania/hypomania and depression. Lithium requires blood monitoring to assure a therapeutic range, and detect problems with deteriorating renal function or hypothyroidism. Patients taking sodium valproate need monitoring of liver function. For Lithium and other mood stabilizers such as sodium valproate and lamotrigine, side effects may include gastrointestinal problems, hair loss, motor problems, fatigue, cognitive impairment, sexual issues, weight gain, skin eruptions and visual disturbances.
Antipsychotics and Atypical Antipsychotics
Antipsychotic medications may include both older conventional drugs such as the anticonvulsants and increasingly the newer atypical antipsychotics. Their primary treatment effect is for acute mania. Anticonvulsant side effects include extrapyramidal symptoms such as tremors or muscle spasms and tardive dyskinesia. Atypical antipsychotic medications can result in metabolic changes resulting in weight gain, high lipid levels, diabetes, dizziness, constipation, skin rashes, cataracts, hypotension, heart problems, seizures, cognitive problems and involuntary movements.
Antidepressants are often prescribed in combination with a mood stabilizer or antipsychotic medication. The general recommendation is to taper and discontinue antidepressants after remission (Jan, 2014). When given alone (unopposed) to patients with a bipolar diagnosis, mania may result. Finally, antidepressant mediations can cause gastrointestinal problems, agitation, insomnia, tremors, dry mouth, headaches and sexual problems.
Medication Management Challenges
Medication management can be an ongoing struggle for patients with bipolar disorder, for family and friends of the patient and the professionals treating them. Medication nonadherence or noncompliance is a common problem and occurs for many reasons.
Medication regimens are complex and often expensive. Unpleasant side effects may be annoying and perceived as not increasing quality of life. When seriously depressed, or hyperactive, energy levels and the inability to concentrate may result in nonadherence to the complex medication plan.
When manic, the patient with bipolar disorder may believe they are well, or feel robbed of the positive feelings associated with mania. Energy, competence and creativity may be missed. When the patient feels better, even in a manic state, the patient may believe they are cured and no longer need their medications. Medication physical and emotional side effects are of great concern and cause much noncompliance. It is helpful for the nurse to ask the patient about their physical and emotional struggles for mood stability with prescribed medications. As medications may need to change, the patient s perspective on lack of adherence may be insightful.
Psychosocial therapies assist patients to understand, accept, monitor and manage their disorder. With a chronic disorder that affects physical health, emotional stability and social function, involvement of an entire team is needed to stabilize the patient. All healthcare providers, nurses, advanced practice nurses, physicians and mental health professionals must communicate and coordinate for optimum results. Newly diagnosed patients need referral to mental health professionals and existing bipolar patients with physical health concerns need understanding and support during management of physical health problems. Providers focused on physical problems need to work with the patient’s mental health team to understand and more fully manage the patient’s unique needs.
All nurses need to understand that while there are some commonalities among patients with bipolar disorder, every bipolar disorder patient is unique. A relationship with the patient, his/her family, significant other, and the patient’s mental health professionals benefits all aspects of care for this complex, perplexing and recurring disorder. Medical and nursing care providers need to have the patient’s consent to communicate with their mental health providers for care coordination and continuity. Mental health providers will assist others to better understand effective approaches with the patient, especially in crisis situations.
Evidence Based Psychosocial Treatments for Bipolar Disorder
The psychosocial treatments for bipolar disorder include psychosocial education (PE), cognitive behavioral therapy (CBT), interpersonal social rhythm therapy (IPSRT), and family-focused therapy (FFT). Swartz and Swanson (2014) reviewed the literature from1995-2013 reported the advantages of psychosocial therapies in combination with medications.
The effectiveness of psychoeducation for individuals and groups of patients consists of a number of sessions designed to provide information about the bipolar disorder, discussion to enhance understanding and support for the emotional response to the information. Psychoeducational approach would cover such topics as:
1) Understanding the nature of bipolar disorder and necessary treatments for management to help with stability.
2) Knowledge about signs and symptoms, recognition of risk factors and warning signs of relapse.
3) Development of strategies to cope with stressful life events.
4) Recognizing and developing protective factors in their lives which support treatment compliance.
5) How to access and utilize the health care system to manage their illness and crisis situations if they occur.
Interpersonal Social Rhythm Therapy (IPSRT) IPSRT, a short term approach, helps bipolar disorder patients recognize and manage how changes in sleep and eating routines, social stimulation and other daily routines might impact symptoms associated with mood changes. The philosophy acknowledges the interrelationship between biological and social rhythms. As evidence increases that there is a biological and/or genetic basis for bipolar disorder, IPSRT promotes efforts for stability of routines and minimization of stress. With IPSRT, patients are helped to identify and track the connection between stress and their mood symptoms. By learning new interpersonal skills promoting relationships and minimizing conflicts, the patient can adjust daily routines to achieve a balance of social stimulation with adequate rest.
Cognitive Behavioral Thera py (CBT)
Cognitive behavioral therapy is based on the belief that problematic and chronic emotions can be impacted by distorted and irrational thoughts. How a patient with a bipolar disorder percei ves and thinks about a situation can affect feelings and behaviors. CBT therapists help patients examine how their thinking patterns impact feelings and behaviors related to acknowledging the existence of their bipolar disorder, participation in the treatment plan to achieve adherence and decrease stress.
Family-Focused Therapy (FFT)
Family-focused therapy involves psychoeducation for the patient/family along with medications for the patient. Emphasis is upon communication and problem-solving skills (Miklowitz & Chung, 2016).
Encouraging patients with bipolar disorder and family member caregivers help them to manage their illness through medication compliance and a more complete understanding of the disorder.
Co-morbidities, Mortality and Bipolar Disorder Co-morbidities are common in persons with bipolar disorder. Alcohol and drug abuse, anxiety and panic attacks are not unusual. Suicide and accident rates remain high, but only partially account for the premature death rates in persons with BD. Patients with severe mental illness often have worse physical health than the general population. The negative impact of severe mental illness on clinical outcomes of many other chronic health conditions such as cardiovascular disease, stroke, cancer, diabetes and respiratory illness is recognized (Collins, Tranter, & Irvine, 2012; Jann, 2014; Welsh & McEnany, 2015). In a blog about the physical health and mortality of patients with severe mental illness such as bipolar disorder, Insel (2011) commented about several reports that patients with chronic mental illnesses such as schizophrenia, bipolar disorder and depression lose 25 or more years of life expectancy when compared to persons without mental illness.
Implications for Nursing Care of Patients with Bipolar Disorders and Their Significant Others Nursing care of a patient and family/significant others with bipolar disorder begins with understanding the complexity and recurrent nature of this brain disorder. In a qualitative study of persons with bipolar disorder, three areas were identified: individual, family and health system challenges (Blixen, C., Perzynski, A.T., Bukach, A., Howland, M., & Sajatovic, M., 2016). By understanding bipolar disorder and the potential physical and emotional impacts on patients and those who care about them, nurses in non-psychiatric settings can respond in helpful ways. Each encounter offers opportunities to optimize the patient’s future health status. These opportunities include consideration of safety, future health, emotional support and the environment.
Safety and emotional comfort can influence decisions to seek or participate in care.
If suicidal thoughts are expressed, or not, it is important to ask the question about whether there are thoughts or plans for self-harm. All health care professionals should screen for suicide, alcohol and/or drug use in a non-judgmental and empathetic manner. Suicide risk is increased when the bipolar patient is anxious or agitated, using drugs or alcohol. Previous suicide attempts and/or a family history of suicide also increase the risk.
- Ask the patient about suicidal
- Ask if the patient has a plan, or the means to carry out the
- Take immediate steps for a suicidal patient’s safety by arranging transportation to a local emergency department, as emergency hospitalization may be
- Arrange for prompt evaluation by a mental health
When there is problem with substance use, there is greater risk for physical health problems. Treatment non-compliance and suicide may result from a lack of impulse control. Screening for substance use and encouraging the patient to accept and actively participate in treatment can also be a life-saving intervention. Do not be discouraged if the patient denies substance use, refuses help or relapses. A non-judgmental and empathetic alliance with the patient may help future decisions. Encourage psychoeducational interventions and personal journals describing mood changes and behavior that may increase insights into the negative connection between substance use and quality life. Managing bipolar disorder and other chronic illnesses can be a difficult journey and the nurse’s expertise and support are important to overall health.
- Encourage screenings for prevention and/or management of common health problems (e.g. heart disease or pulmonary disease, diabetes, and stroke).
- Promote education and insights about how substances such as alcohol, nicotine and drugs may interfere with bipolar disorder-management.
- Encourage patients with bipolar disorder to get screenings and assist them in managing any health issues found.
Listening with compassion builds a trusting relationship. This may prompt a patient with bipolar disorder and his/her family or significant others to share about living with bipolar disorder. Ask about how they think their physical and psychosocial treatments are working. Request consent to discuss their care with mental health providers.
Family and significant others are a critical support system and safety net for a person living with bipolar disorder. These caregivers may also be exhausted, feel overwhelmed, and totally alone in their efforts to provide support. Nurses will meet family and significant others in as many ways as they will meet the patient: in crisis situations, medical health problems, or social situations. The family may contact a patient’s medical caregiver when the patient is in crisis and does not have, or has refused, on-going mental health assistance.
- Listen and acknowledge expressed concerns, or any concerns that may be
- Refer to local mental health associations or crisis centers, for information and additional
- Encourage peer support groups and/or family-to family
Many national organizations such as the National Alliance on Mental Illness (NAM!) and the Depression and Bipolar Support Alliance (DBSA) have local chapters for patient and family participation. Support from others who are trying to help a loved one cope with bipolar disorder may help with practical suggestions, or the knowledge that others understand the struggles they face.
Nurses working in any health care setting can work to make the environment friendly, less intimidating and more welcoming to patients and family members living with bipolar disorder. All people with mental illness, including bipolar disorder, are exposed to stigma in everyday aspects of their life. Stigma about mental health can make relatively simple decisions more complicated. Applying for a job, finding housing, or making friends are just a few of the day to-day challenges encountered.
- Make certain informational pamphlets, magazine and visuals in your health settings’ waiting and public areas include mental health topics, in addition to the usual physical health materials.
- Include concerns about stigma and mental health topics for staff educational development.
Working with a patient with bipolar disorder and their significant others can be difficult in non-psychiatric settings, but forming an alliance with them can be life-saving or life-enriching. The benefit of helping the patient feel comfortable in accessing health care for physical and mental health screening, prevention and care may never be known by the non-psychiatric nurse. Be assured that compassionate and empathetic communication and care does impact positive outcomes. Nurses assist patients living with bipolar disorder to manage life-threatening and life-sustaining health and emotional problems, as well providing support to their significant others.
Communication and coordination of care in partnership with mental health providers impacts the quality and length of their lives. Nurses in any setting – especially non-psychiatric nurses – are in a unique position to enhance care for the person with bipolar disorder.
Risk Factors Contributing to Poor Physical Health in a Bipolar Disorder Patient
- Poor diet
- Inadequate exercise
- Irregular sleep patterns
- Chronic stress responses
- Substance use
Health Care Access and Utilization
- Social factors -isolation, homelessness, lack of insurance
- Lack of access to preventive healthcare or a “medical home”
- Medication side effects used for treatment
- Feeling stigmatized as a person with a mental disorder
Health Care System
- Inadequate care coordination for psychiatric and physical health conditions
- Inadequate education and staff development about bipolar disorder patient care among non-psychiatric caregivers
Resources for Support of the Bipolar Disorder Patient and Significant Others
Depression and Bipolar Support Alliance www.dbsalliance. org
Offers information about living with bipolar disorder
and finding support groups
Mental Health America www.nmha.org
Provides fact sheets and screening tools on bipolar disorder, including local resources
National Alliance on Mental Illness (NAMI) www.nami.org
Provides fact sheets, updates of recent research and personal accounts of living with bipolar disorder.
National Institute of Mental Health www.nimh.nih.org
Up-to-date resources and the latest research about all mental illnesses: statistics on prevalence, research about etiology, and current treatments.
American Psychiatric Association. (2015). Help with bipolar disorders. Retrieved from httos://www.psychiatry.org/patients-families /bipolar-disorder
Blixen, C., Perzynski, A.T., Bokach , A., Howland, M., & Sajatovic, M. (2016). Patients’ perceptions of barriers to self-managing bipolar disorder: A qualitative study. International Journal Social Psychiat1 y, 62(7 ), 635- 644.
Collins, E.E., Tranter, S.S., & Irvine, F.F. (2012). The physical health of the seriously mentally ill: An overview of the literature . Journal of Psychiatric and Mental Health Nursing, 19(7), 638-646.
Cullison, S.K. & Resch, W.J. (2014). How should you use the lab to monitor patients taking a mood stabilizer?
Current Psychiatry, 13(7), 51 -55.
Diagnostic and Statistical Manual of Mental Disorders: 5th Edition . (2013). Eds. American Psychiatric Association. American Psychiatric Association Publishing.
Insel, T. (2011). No health without mental health. Retrieved from
https : //www .nimh.nih.go /about’di rectors/thomas- i nsel/blog/2011 /no-health-withouL-mental-heal t h . html
Jann, J.W. (2014). Diagnosis and treatment of bipolar disorders in adults: A review of the evidence on pharmacologic treatments. American Health and Drug Benefits, 7(9), 489-499.
Krans, B. & Cherney, K. (2016). The history of bipolar disorder. Retrieved from ht1p://www.healthline.com /health/bipolar-disorder /history-bip
Miklowitz, D.J. & Chung, B. (2016). Family-focused therapy for bipolar disorder: Reflections on 30 years of research. Family Process. 55( 3 ), 483-99. doi: 10.1 1 1 1/famp.12237.
National Institutes of Health. (2016). Retrieved from hrtps://v1ww.nimh .nih.gov/heaHh/topics/bi polar-di order Swartz, H. A. & Swanson, J. (2014). Psychotherapy for bipolar disorder in adults: A review of lhe evidence.
Focus (American Psychiatric Publication), 12(3): 251-266. doi: 10:1176/appi.focus. 12.3.251
Welsh, E.R. & McEnany, G.P. (2015). Approaches to reduce physical comorbidity in individuals diagnosed with mental illness. Journal of Psychosocial Nursing and Mental Health Services, 53(2), 32-37.