Bipolar Disorder — GCC Nursing Guide

Bipolar I

At least one manic episode ≥ 7 days (or any duration if hospitalisation required or psychotic features present). Depressive episodes common but not required for diagnosis.

Most severe form Psychosis possible

Bipolar II

Hypomanic episodes (≥ 4 days, no hospitalisation, no psychosis) plus at least one major depressive episode. Never a full manic episode — if one occurs, reclassify as Bipolar I.

Depression predominant No hospitalisation in hypomania

Cyclothymia

Chronic fluctuating mood — hypomanic symptoms + depressive symptoms for ≥ 2 years (1 year in children/adolescents), never meeting full criteria for hypomania or major depression. Risk factor for developing Bipolar I/II.

Specifiers

Mixed features: manic episode with ≥ 3 concurrent depressive symptoms (or vice versa) — higher suicide risk
Rapid cycling: ≥ 4 distinct mood episodes per year (any polarity). Associated with hypothyroidism, substance use, antidepressant use
Psychotic features: mood-congruent or mood-incongruent
Peripartum onset, seasonal pattern

DSM-5 Criteria — Manic Episode

Distinct period of abnormally elevated/expansive/irritable mood + increased goal-directed activity or energy, lasting ≥ 7 days (most of each day). Must include ≥ 3 of the following (≥ 4 if mood is only irritable):

Distractibility — attention easily drawn to irrelevant external stimuli

Insomnia (decreased need for sleep) — feels rested after 3 hours; distinguish from insomnia in depression where patient wants sleep but cannot

Grandiosity — inflated self-esteem; may become delusional (special powers, divine mission)

Flight of ideas — racing thoughts, nearly continuous flow of accelerated speech jumping between topics

Activity increase — increased goal-directed activity (social, work, sexual) or psychomotor agitation

Speech pressured — rapid, loud, difficult to interrupt; tangential

Thoughtlessness / risk-taking — reckless spending, sexual disinhibition, poor business decisions, substance use

Criteria C: Severe enough to cause marked impairment, require hospitalisation, or include psychotic features. NOT due to substances or medical condition.

Mental State Examination (MSE)

MSE During Mania

Appearance: bright/flamboyant clothing, dishevelled if severe, reduced personal care
Behaviour: overactive, intrusive, disinhibited, aggressive if frustrated
Speech: pressured, loud, rapid, difficult to interrupt, tangential
Mood: elevated, euphoric or irritable/dysphoric
Thought form: flight of ideas, loosening of associations, clang associations
Thought content: grandiose delusions, persecutory delusions, thought insertion/broadcast
Perception: auditory hallucinations (mood-congruent), visual hallucinations less common
Cognition: distractible, impaired concentration, poor judgment
Insight: typically severely impaired — does not recognise illness

MSE During Bipolar Depression

Appearance: neglected, psychomotor retardation, hunched posture
Behaviour: slowed, withdrawn, minimal eye contact
Speech: slow, quiet, limited spontaneity, long latency
Mood: depressed, hopeless, anhedonic; may include diurnal variation (worse AM)
Thought form: poverty of thought, rumination
Thought content: guilt, worthlessness, nihilistic delusions, suicidal ideation
Perception: mood-congruent hallucinations (e.g. voices confirming worthlessness)
Cognition: poor concentration, pseudodementia picture
Insight: may be preserved but skewed negatively

Differential Diagnoses

Condition	Key Distinguishing Features	Nursing Note
Schizophrenia	Negative symptoms prominent, mood symptoms secondary, psychosis not tied to mood episodes, chronic deteriorating course	Assess mood episode timeline carefully
Schizoaffective disorder	Psychotic symptoms persist for ≥ 2 weeks independent of mood episode; both schizophrenic and mood criteria met	Requires both mood stabiliser and antipsychotic long-term
Borderline personality disorder	Mood shifts minutes-hours (not days-weeks), related to interpersonal triggers, chronic emptiness, identity disturbance	DBT-based approaches; careful medication review
Substance-induced mood disorder	Temporal relationship with substance use; resolves with abstinence (usually within 4 weeks)	Full substance history; urine drug screen essential
ADHD	Childhood onset, consistent hyperactivity/inattention without episodic mood elevation; no grandiosity	Distinguish in young patients; stimulants can trigger mania
Medical causes	Hyperthyroidism, Cushing's, CNS lesions, corticosteroid use, HIV encephalopathy	TFTs, full blood count, neurological examination

Acute Mania Nursing Priority: Safety first — self-harm, aggression, financial harm, sexual disinhibition. Inpatient admission indicated if: danger to self/others, inability to care for self, severe psychosis, rapid deterioration.

Inpatient Indications

Imminent danger to self or others
Severe psychotic features
Unable to care for self (food, hydration)
Profound sleep deprivation (<3h/night)
Rapid deterioration in community
Failed community management
Significant social/financial harm ongoing

Community Management (Mild-Moderate)

Daily or twice-daily nurse contact initially
Carer present and informed
Structured daily routine, sleep protection
Medication compliance monitoring
Substance avoidance education
Crisis plan activated with clear escalation pathway
Reduce stimulation, cancel non-essential commitments

De-escalation Techniques

Environmental & Non-verbal De-escalation

Calm, low-stimulation environment — dim lighting, quiet room, reduce staff numbers
Non-confrontational approach — avoid direct challenge of grandiose beliefs
Personal space — maintain ≥ 1 arm's length, avoid blocking exits
Calm, steady voice — slow speech rate, neutral tone

Acknowledge feelings before redirecting behaviour
Offer choices to restore sense of control
Remove audience — reduces disinhibited behaviour
Limit-setting — clear, calm, consistent boundaries without threats

Pharmacological Management of Acute Mania

Drug	Route/Dose	Indication	Key Nursing Points
Lorazepam	IM 1–2 mg; can repeat after 30 min (max 4 mg/episode)	First-line for acute agitation (NICE TE protocol)	Monitor respiratory rate, O₂ sat, BP post-dose; have flumazenil available
Haloperidol	IM 5 mg; max 10–20 mg/24h	Agitation + psychotic features; combine with lorazepam with caution	EPS risk; monitor for acute dystonia — have procyclidine ready; avoid in prolonged QTc
Olanzapine	IM 10 mg (5 mg if elderly/low weight); do NOT combine IM with IV/IM benzodiazepine <1h	Agitation; broader sedation	Serious interaction risk: IM olanzapine + benzodiazepine = respiratory collapse; 1-hour minimum gap
Lithium	PO 400–600 mg BD/TDS; titrate to level 0.8–1.0 mmol/L in acute mania	Mood stabiliser — first-line initiation	Takes 5–7 days for effect; check renal/TFTs before starting; check level after 5 days
Valproate (semisodium)	PO 500 mg BD up to 2500 mg/day; loading dose 20 mg/kg in acute mania	Alternative to lithium; faster onset	LFTs/FBC before starting; ABSOLUTELY CONTRAINDICATED in women of childbearing potential without PREVENT programme
Olanzapine (oral)	PO 10–20 mg nocte	Adjunct antipsychotic in acute mania	Metabolic monitoring; weight, glucose, lipids at baseline
Quetiapine	PO 400–800 mg/day (divided doses)	Mania + mixed features; also useful for sleep	Sedation, postural hypotension; gradual titration
Zopiclone	PO 7.5 mg nocte, short-term only	Sleep promotion during acute mania	Limit to 2–4 weeks; dependence risk; not a mood stabiliser

Monitor every 5–15 minutes for the first hour, then every 30 minutes for 2 hours. Document all observations. Resuscitation equipment MUST be available.

Component	What to Monitor	Action if Abnormal
A — Airway	Patent, no obstruction; recovery position if drowsy	Airway adjunct; call for help immediately
B — Breathing	Respiratory rate (target 12–20/min), O₂ saturation ≥ 95%	O₂ therapy; flumazenil if benzodiazepine-induced respiratory depression
C — Circulation	HR, BP (postural drop), pulse rhythm; ECG if QTc concern	IV access; fluid challenge if hypotensive; cardiac monitoring
D — Disability	GCS/level of consciousness, pupils, blood glucose	Neurological review if GCS drops; glucose if hypoglycaemia
E — Exposure	Temperature (hyperthermia = NMS risk), skin colour, signs of NMS (rigidity/diaphoresis)	Stop antipsychotic; urgent medical review for NMS; cooling

NMS warning signs: hyperthermia, muscle rigidity, autonomic instability, altered consciousness — discontinue antipsychotic immediately, contact medical team.

Risk Assessment in Acute Mania

Key Risk Domains

Self-harm/suicide: risk highest in mixed episodes and during transition to depression
Aggression/violence: when frustrated, confronted, or delusionally threatened
Financial harm: reckless spending, gambling, business decisions — notify family
Sexual disinhibition: STI risk, relationship harm, potential exploitation
Vulnerability: exploitation by others during disinhibited state

Protective Factors to Document

Therapeutic alliance with clinical team
Family / carer support and availability
Absence of substance misuse
Adherent to medications previously
Recognised own relapse signatures in past
Religious or spiritual beliefs (can be protective)
Social role obligations (children, work)

Lithium

Lithium — Key Facts

Therapeutic range: 0.6–1.0 mmol/L (maintenance); 0.8–1.0 in acute mania
Sample timing: 12 hours post-last dose (trough level)
Narrow therapeutic index — toxic levels are close to therapeutic
Excreted entirely by kidneys — renal function critical
Competes with sodium — low sodium diet or dehydration increases levels
Half-life: 18–36 hours (longer in elderly/renal impairment)

Drug Interactions (Level-Raising)

NSAIDs — reduce renal prostaglandins, decrease lithium clearance ↑ levels by up to 25%
ACE inhibitors / ARBs — reduce GFR, raise lithium levels significantly
Thiazide diuretics — sodium depletion drives lithium retention
Low-sodium diet / dehydration / vomiting / diarrhoea / fever — all increase levels
Metronidazole, tetracycline — modest increases

Lethargy / Level elevated — check serum level; early sign

Involuntary movements / Irregular heartbeat — ECG changes (T-wave flattening/inversion, widened QRS in severe)

Tremor (coarse) — distinguish from fine intention tremor (therapeutic); coarse tremor = toxicity

Hyperreflexia / Hypotension

Incontinence / Impaired consciousness

Unsteady gait / ataxia

Mental confusion / vomiting / diarrhoea

Toxicity Levels

1.0–1.5 mmol/L (Mild): Nausea, vomiting, diarrhoea, fine tremor, polyuria — monitor closely, consider dose reduction

1.5–2.0 mmol/L (Moderate): Coarse tremor, confusion, drowsiness, ataxia, slurred speech — HOLD lithium, rehydrate, urgent level recheck

> 2.0 mmol/L (Severe): Seizures, cardiovascular collapse, coma — EMERGENCY; IV fluids, dialysis may be required; no specific antidote

Management: Stop lithium, IV normal saline (renal excretion), monitor electrolytes/renal function. Haemodialysis for level > 3.5 mmol/L or severe clinical features.

Test	Before Starting	During Titration	Maintenance (Stable)
Lithium level	—	5–7 days after each dose change (12h trough)	Every 3–6 months
Renal function (U&E, eGFR)	✓ Baseline	Every 6 months initially	Every 6 months (annually if stable > 5 years)
Thyroid (TFTs)	✓ Baseline	Every 6 months	Every 6–12 months (lithium causes hypothyroidism in ~40%)
Calcium / PTH	✓ Baseline	If symptomatic	Annual (hyperparathyroidism risk)
ECG	✓ Baseline (especially if cardiac history)	If level elevated	Annually in elderly
Weight / BMI	✓ Baseline	Monthly	Every 3 months
Pregnancy test	Women of childbearing age	If pregnancy suspected	Discuss contraception at each review

Teratogenicity: Lithium associated with Ebstein's anomaly (tricuspid valve malformation) — risk ~0.05–0.1% (absolute risk small but 10–20x baseline). Discuss risks vs benefits if pregnant; fetal echocardiography recommended if exposed in first trimester.

Sodium Valproate

Sodium Valproate — Key Facts

Effective for acute mania and maintenance
Faster onset than lithium in acute mania
Inhibits GABA transaminase — increases GABA activity
Therapeutic level: 50–100 mg/L (guidance varies)
Monitoring: LFTs, FBC, weight at baseline and regularly
Common side effects: weight gain, hair loss, tremor, sedation, polycystic ovarian features

Valproate & Women of Childbearing Age

SEVERE TERATOGEN — Neural tube defects (1–2%), autism spectrum disorder, developmental delay, congenital malformations. Risk persists throughout pregnancy.

PREVENT Programme (UK MHRA): Mandatory annual review, pregnancy prevention plan, two forms of contraception
Must not be prescribed unless alternatives tried and failed
GCC equivalent: not standardised in all countries — nurse must counsel proactively
Patient card/acknowledgement form required

Lamotrigine

Lamotrigine — Key Facts

First-line for bipolar depression and depression-dominant maintenance
Does NOT effectively treat acute mania
Mechanism: sodium channel blocker, reduces glutamate release
Slow titration mandatory — start 25 mg/day, increase every 2 weeks
Valproate doubles lamotrigine levels — halve starting dose
Carbamazepine halves lamotrigine levels — double dose

Stevens-Johnson Syndrome (SJS) risk — rare but life-threatening skin reaction. Increased risk with: rapid dose titration, co-administration with valproate, in children. Nurse must educate: report any rash immediately — stop drug pending review.

If rash develops — stop immediately and seek urgent review
Relatively safe in pregnancy compared to other mood stabilisers
No blood level monitoring routinely required

Treating Bipolar Depression

Critical Principle: Antidepressants should NOT be used alone in bipolar depression — risk of triggering manic switch (especially TCAs) and cycle acceleration. Always ensure a mood stabiliser is in place first.

Evidence-Based Options for Bipolar Depression

Quetiapine — NICE first-line; 300 mg/day for bipolar depression; also has maintenance evidence; sedating — useful if sleep disrupted
Lamotrigine — effective for depression phase; slow titration required; add to existing mood stabiliser
Lithium augmentation — ensure therapeutic level maintained
Lurasidone (where available) — newer evidence; less metabolic burden
Olanzapine + fluoxetine (Symbyax) — used in some guidelines; metabolic monitoring essential

What to Avoid

Antidepressants alone — risk of manic switch, rapid cycling induction
TCAs — highest manic switch risk
If antidepressant added — always with concurrent mood stabiliser; monitor closely for mood elevation
Stopping mood stabiliser on starting antidepressant — common error
Stimulant medications — ADHD comorbidity management requires specialist input

Maintenance & Relapse Prevention

Maintenance Goals

Prevent relapse of both mania and depression
Reduce episode frequency and severity over time
Preserve social/occupational functioning
Minimise medication side effects
Support engagement with psychosocial interventions

Mood charting (paper or app) — detect pattern changes early
Sleep diary — sleep disruption is earliest relapse indicator
Activity diary — detect hypomanic behavioural changes
Regular medication reviews — side effects impact adherence
Annual physical health checks (see below)

Early Warning Signs — Mania

Reduced sleep without fatigue
Increased energy and activity level
Racing thoughts, mind feels sharper
Increased spending or risk-taking
Increased sociability or calls/texts
Irritability or heightened sensitivity
Stopping medication ("I feel well / I don't need it")
Alcohol or substance use increasing

Early Warning Signs — Depression

Increased sleep or insomnia
Withdrawal from activities/friends
Loss of interest or enjoyment
Slowing down, fatigue
Increased negative thinking, hopelessness
Appetite change (usually decreased)
Missing appointments
Suicidal ideation emerging

Crisis Plan: Every patient should have a written crisis plan (Joint Crisis Plan/Advance Statement) including: personal warning signs, agreed first responses, emergency contacts, preferred/refused treatments. Family/carers should have a copy.

Sleep as Mood Regulation

Sleep — The Most Powerful Mood Stabiliser

Sleep disruption is both a prodrome and a precipitant of mood episodes. Sleep hygiene education is a core nursing intervention:

Fixed wake time regardless of sleep quality
Avoid napping during manic prodrome
Dark, cool, quiet sleep environment
No screens 1 hour before bed

Avoid caffeine after 2 PM
Regular exercise (morning preferred)
Avoid alcohol (disrupts sleep architecture)
Social rhythm therapy — regularise daily routines

Physical Health Monitoring

Annual Physical Health Review (Metabolic Syndrome / Cardiovascular Risk)

Antipsychotics used in bipolar disorder significantly increase metabolic syndrome risk. Nurse-led annual monitoring is essential:

Parameter	Target / Action	Frequency
Weight / BMI	≥ 7% weight gain = review medication	Monthly for first 3 months, then quarterly
Waist circumference	Men > 94 cm / Women > 80 cm = metabolic risk	Annually (minimum)
Fasting blood glucose / HbA1c	Action if fasting glucose ≥ 5.6 mmol/L	Baseline, 3 months, then annually
Fasting lipid profile	Total cholesterol < 5 mmol/L	Baseline, 3 months, then annually
Blood pressure	Target < 130/80 mmHg	Monthly for 3 months, then annually
ECG	QTc < 450 ms (men) / < 470 ms (women)	Baseline; repeat if medication change
Prolactin	If symptomatic (amenorrhoea, galactorrhoea)	At initiation; if symptoms arise

Substance Misuse

Substance Misuse & Bipolar Disorder

High comorbidity: ~50–60% of people with bipolar disorder have a lifetime substance use disorder. This is the single strongest predictor of poor outcome.

Cannabis: precipitates and prolongs episodes; increases psychosis risk
Alcohol: disrupts sleep, interacts with lithium/valproate, depressant phase trigger
Stimulants (cocaine, amphetamines): directly trigger mania
Khat (qat): stimulant properties — documented trigger in GCC/East African populations

Dual diagnosis requires integrated treatment
AUDIT-C and DAST-10 screening tools routinely
Motivational interviewing by nursing staff
Non-judgmental stance — stigma a major barrier to disclosure

Mental State Examination Framework

MSE Components — Nursing Assessment

Domain	What to Assess	Specific Bipolar Observations
Appearance	Dress, hygiene, eye contact, posture	Flamboyant/disinhibited in mania; neglected/slowed in depression
Behaviour	Activity level, cooperation, agitation	Overactive/intrusive vs retarded; engagement with ward milieu
Speech	Rate, volume, tone, coherence	Pressured/loud/rapid (mania) vs slow/quiet/sparse (depression)
Mood (subjective)	"How are you feeling?" — patient's own words	Euphoric/irritable vs hopeless/empty; use 0–10 scale
Affect (objective)	Observed emotional expression, congruence	Elevated/labile/irritable vs flat/blunted; mood-congruent vs incongruent
Thought form	Coherence, logical flow	Flight of ideas, tangentiality, loosening of associations
Thought content	Beliefs, worries, themes	Grandiose/persecutory delusions; suicidal ideation; nihilistic content
Perception	Hallucinations (auditory, visual, other)	Mood-congruent AH; command hallucinations — assess compliance
Cognition	Orientation, memory, concentration, executive function	Distractible/impaired judgment in mania; pseudodementia in depression
Insight	Illness awareness, treatment acceptance	Often severely impaired in mania — impacts medication adherence and safety
Risk	Self-harm, suicide, harm to others, self-neglect	See risk frameworks below

Risk Assessment Frameworks

C-SSRS — Columbia Suicide Severity Rating Scale

Ideation: passive wish to be dead → active ideation without plan → with plan → with intent
Behaviour: preparatory acts → aborted/interrupted attempts → actual attempt
Higher score = higher risk; guides escalation decisions
Ask directly: "Are you having thoughts of ending your life?" — does NOT increase risk
Document frequency, intensity, duration of ideation

HCR-20 — Violence Risk Assessment

H (Historical): previous violence, age of first, psychopathy, mental disorder, substance misuse, personality disorder, early maladjustment, employment, relationship instability, prior supervision failures
C (Clinical): current mental disorder, substance use, insight, symptoms, treatment responsiveness
R (Risk Management): feasibility of plans, exposure to destabilisers, personal support, treatment compliance, stress
Structured professional judgment — not purely actuarial

De-escalation — LEAPS Framework

Listen — Active listening; do not interrupt; allow patient to express feelings without judgment; use silence purposefully

Empathise — Reflect feelings: "It sounds like you're feeling very frustrated right now." Validate the experience without reinforcing delusional content

Agree — Find points of agreement where genuine; negotiate around areas of disagreement; avoid power struggles

Partner — Position yourself as working with the patient, not against them: "Let's figure this out together." Collaborative care approach

Summarise — Reflect back what has been agreed; confirm next steps; thank patient for engaging; close on a positive note

Legal Framework — Mental Health Act / GCC Involuntary Admission

UK MHA Framework (GCC Equivalent Reference)

Key Sections (UK MHA 1983)

Section 2: Assessment — up to 28 days; 2 doctors + AMHP
Section 3: Treatment — up to 6 months; renewable
Section 4: Emergency admission — 72 hours; 1 doctor
Section 136: Police power — place of safety from public; 24 hours
Section 5(2): Doctor's holding power (inpatient) — 72 hours
Section 5(4): Nurse's holding power — 6 hours

GCC Involuntary Admission Context

UAE: Mental Health Law No. 28 (2021) — DHA/MOHAP framework; focuses on rights, involuntary admission requires psychiatrist + second opinion
Saudi Arabia: Mental Health Law — Ministerial Order; admission requires 2 psychiatrists; guardianship system for decisions
Qatar: Law No. 16 (2016) — independent committee review for involuntary treatment
Kuwait: Mental Health Law (1994, amended) — court order may be required
Key difference: Family role often more significant in GCC; guardian consent commonly required/sought alongside patient rights

Recovery-Oriented & Psychosocial Care

Psychoeducation Priorities

Nature of bipolar disorder — episodic, treatable, manageable
Importance of medication adherence even when well
Personal relapse signature identification
Sleep hygiene as primary prevention
Substance avoidance — evidence and harm
Stress management and social rhythm therapy
Crisis planning — when and how to seek help
Carer involvement with patient consent

Carer Education

Recognise personal relapse indicators specific to this patient
Respond early — contact team before crisis develops
How to manage manic behaviour (calm, not confrontational)
Financial safeguards during mania (shared accounts, power of attorney)
Carer's own wellbeing — support organisations (Carers UK, Bipolar UK)
What to do in a crisis — who to call, what to say
Role of family in GCC: higher involvement expected; navigating patient confidentiality

GCC-Specific Clinical & Cultural Context

Epidemiology & Social Context in the GCC

Higher rates of mood disorders in young GCC nationals — attributed to rapid modernisation, identity conflict between traditional and contemporary values
Stigma is a major barrier — mental illness often concealed from family; fear of job loss, unmarriageability, social exclusion
Family-centred decision-making — patient may defer to family elder; nurse must respect while ensuring patient rights are upheld
Khat (qat) use — stimulant properties; documented trigger for manic episodes; used in Yemen, parts of East Africa; some diaspora communities in GCC

Cannabis use — increasingly used among youth in GCC despite legal restrictions; significant trigger for bipolar episodes and psychosis
Expatriate workforce — work stress, separation from family, isolation may precipitate first episodes
Religious coping — Islam may be a protective factor; religious leaders may discourage psychiatric treatment; nurse should engage respectfully
Language barriers — diverse expat population; bilingual written resources needed; interpreter services essential

Medication Infrastructure in GCC

Lithium: available across GCC; monitoring infrastructure (renal/TFT labs) present in main hospitals; community monitoring less consistent
Valproate PREVENT equivalent: not standardised across all GCC countries — nurse must take responsibility for counselling women of childbearing age; document discussions
Lamotrigine: available in most GCC hospitals; rash education essential as patients may not seek medical attention for mild rash
Clozapine: available with monitoring; used for treatment-resistant bipolar with psychosis
Rapid tranquillisation protocols: vary by institution; nurses should know their hospital's specific protocol and available medications

Nursing Regulatory Frameworks

DHA (Dubai Health Authority): licenses nurses in Dubai; scope of practice includes psychosocial assessment, medication administration, patient education
DOH (Department of Health Abu Dhabi): separate licensing authority for Abu Dhabi; similar scope
SCFHS (Saudi Commission for Health Specialties): Saudi licensing body; nursing specialties including psychiatric nursing recognised
MOH UAE (Federal level): overall standards; Northern Emirates
Nurses must know their specific jurisdiction's scope for involuntary holding powers, medication administration authority, and documentation requirements

DHA / DOH / SCFHS Exam High-Yield Topics

Lithium Toxicity — High-Yield Exam Points

Therapeutic range: 0.6–1.0 mmol/L; toxicity threshold: > 1.5 mmol/L
Mild toxicity (1.0–1.5): GI symptoms, fine-to-coarse tremor
Moderate (1.5–2.0): confusion, ataxia, slurred speech — HOLD LITHIUM
Severe (> 2.0): seizures, coma, arrhythmia — EMERGENCY / consider dialysis
Sample must be taken 12 hours post-dose (trough)
NSAIDs and ACEi raise lithium levels — memorise this
Dehydration raises levels — hydration is a nursing priority
Teratogen: Ebstein's anomaly
No specific antidote — supportive care / dialysis
Antidote for benzodiazepine RT: flumazenil

Mania Criteria — High-Yield Exam Points

Bipolar I: manic episode ≥ 7 days OR any duration if hospitalised/psychotic
Bipolar II: hypomania ≥ 4 days + major depressive episode; NO full mania
Hypomania: no hospitalisation, no psychosis, no marked impairment
DIGFAST: D-I-G-F-A-S-T (need ≥ 3 of 7; ≥ 4 if only irritable)
Rapid cycling: ≥ 4 episodes/year; associated with hypothyroidism
Mixed episode: mania + ≥ 3 depressive features simultaneously — HIGHEST suicide risk
Cyclothymia: 2 years of subthreshold mood swings
Valproate: AVOID in women of childbearing age (teratogen)

Mood Stabiliser Monitoring — Exam Summary

Drug	Key Monitoring	Critical Safety Point
Lithium	Level, U&E, TFTs q3-6m	12h trough; NSAIDs/ACEi raise levels
Valproate	LFTs, FBC, weight	Contraindicated WOCBA without PREVENT
Lamotrigine	Rash surveillance	Slow titration; SJS risk; halve dose with valproate
Quetiapine	Weight, glucose, lipids, BP, ECG	Metabolic syndrome; QTc prolongation
Olanzapine	Weight, glucose, lipids	IM + IM benzodiazepine = respiratory collapse (1h gap)

Nursing Actions — Exam-Style Questions

Patient refuses lithium: assess insight; psychoeducation; consider MHA if risk high
Coarse tremor on lithium: check level urgently; hold if > 1.5 mmol/L
Rash on lamotrigine: STOP immediately; urgent dermatology/psychiatry review for SJS
Post-RT patient unconscious: recovery position, ABCDE, call for help
Manic patient wants to leave: assess capacity; if no capacity, consider MHA/involuntary holding
Valproate in young woman: contraception counselling; document; explore alternatives
Lithium level 2.3 mmol/L, confused patient: EMERGENCY — hold lithium, IV fluids, medical review, consider dialysis

Interactive Tool — Lithium Toxicity Risk Checker