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Chapter 17 Bipolar and Related Disorders Copyright ©2019 F.A. Davis Company Introduction § Mood is defined as a pervasive and sustained emotion that may have a major influence on a person’s perception of the world. § Examples of mood: Depression, joy, elation, anger, anxiety § Affect is described as...

Chapter 17 Bipolar and Related Disorders Copyright ©2019 F.A. Davis Company Introduction § Mood is defined as a pervasive and sustained emotion that may have a major influence on a person’s perception of the world. § Examples of mood: Depression, joy, elation, anger, anxiety § Affect is described as the emotional reaction associated with an experience. Copyright ©2019 F.A. Davis Company Introduction (continued) § Mania is an alteration in mood that is expressed by feelings of elation, inflated selfesteem, grandiosity, hyperactivity, agitation, and accelerated thinking and speaking. § Mania can occur as a biological (organic) or psychological disorder, or as a response to substance use or a general medical condition. Copyright ©2019 F.A. Davis Company Historical Perspective § Documentation of the symptoms associated with bipolar disorder dates back to the 2nd century in Greece. § In early writings, mania was categorized with all forms of “severe madness.” Copyright ©2019 F.A. Davis Company Historical Perspective (continued) § The modern concept of manic-depressive illness began to emerge in the 19th century, with terms such as “dual-form insanity” and “circular insanity.” § The term manic-depressive was first coined in 1913, and the American Psychiatric Association adopted the term bipolar disorder in 1980. § In 1854, Jules Baillarger presented information to the French Imperial Academy of Medicine in which he used the term “dual-form insanity” to describe the illness. In the same year, Jean-Pierre Falret described the same disorder, which he termed “circular insanity.” § Contemporary thinking has been shaped a great deal by the works of Emil Kraepelin, who first coined the term manic-depressive in 1913. His approach became the most widely accepted theory of the early 1930s. Copyright ©2019 F.A. Davis Company Epidemiology § Bipolar disorder affects approximately 4.4% of American adults, and 82.9% of these cases are considered severe § Gender incidence is roughly equal. § Average age at onset is 25 years, and following the first manic episode, the disorder tends to be recurrent. Bipolar disorder is associated with increased mortality in general and particularly with death by suicide § Unlike depressive disorders, Occurs more often in the higher socioeconomic classes with an overrepresentation among socially active, creative individuals § Sixth-leading cause of disability in the middle-age group, but for those who respond to lithium treatment (about 33% of those treated with lithium), bipolar disorder may be completely treatable, with no further episodes. Unfortunately, many individuals go for years without an accurate diagnosis or treatment, and for some the consequences can be devastating. Copyright ©2019 F.A. Davis Company Bipolar Disorder § Bipolar disorder is characterized by mood swings from profound depression to extreme euphoria (mania), with intervening periods of normalcy. § Delusions or hallucinations may or may not be part of clinical picture. § Onset of symptoms may reflect seasonal pattern. § A somewhat milder form of mania is called hypomania. Copyright ©2019 F.A. Davis Company Types of Bipolar Disorders § Bipolar 1 disorder § Client is experiencing, or has experienced, a full syndrome of manic or mixed symptoms. § May also have experienced episodes of depression Copyright ©2019 F.A. Davis Company Types of Bipolar Disorders (continued_1) § Bipolar 2 disorder § Characterized by bouts of major depression with episodic occurrence of hypomania § Has never met criteria for full manic episode § Bipolar II disorder is characterized by recurrent bouts of major depression with episodic occurrence of hypomania. The individual may present with symptoms of depression or hypomania. The client has never experienced a full manic episode. The diagnosis may specify whether the current or most recent episode is hypomanic, depressed, or with mixed features. If the current syndrome is a major depressive episode, psychotic or catatonic features may be present. Copyright ©2019 F.A. Davis Company Types of Bipolar Disorders (continued_2) § Cyclothymic disorder Chronic mood disturbance At least 2-year duration Numerous episodes of hypomania and depressed mood of insufficient severity to meet the criteria for either bipolar 1 or 2 disorder Copyright ©2019 F.A. Davis Company Types of Bipolar Disorders (continued_3) § Substance- and medication-induced bipolar disorder A disturbance of mood (depression or mania) that is considered to be the direct result of the physiological effects of a substance (for example, ingestion of or withdrawal from a drug of abuse or a medication or other treatment) Bipolar II disorder is characterized by recurrent bouts of major depression with episodic occurrence of hypomania. The individual may present with symptoms of depression or hypomania. The client has never experienced a full manic episode. The diagnosis may specify whether the current or most recent episode is hypomanic, depressed, or with mixed features. If the current syndrome is a major depressive episode, psychotic or catatonic features may be present. Copyright ©2019 F.A. Davis Company Types of Bipolar Disorders (continued_4) § Bipolar disorder due to another medical condition Characterized by an abnormally and persistently elevated, expansive, or irritable mood and excessive activity or energy that is judged to be the result of direct physiological effects of another medical condition Copyright ©2019 F.A. Davis Company Clicker Question 1 1. A suicidal client with a history of manic behavior is admitted to the emergency department. The client’s diagnosis is documented as bipolar 1 disorder: current episode depressed. What is the rationale for this diagnosis instead of a diagnosis of major depressive disorder? A. The physician does not believe the client is suffering from major depression. B. The client has experienced a manic episode in the past. C. The client does not exhibit psychotic symptoms. D. There is no history of major depression in the client’s family. Copyright ©2019 F.A. Davis Company Clicker Question Answer 1 Correct Answer: B The client’s past history of mania and current suicide attempt support the diagnosis of Bipolar 1 Disorder: Current Episode Depressed. According to the D S M-5 criteria, a manic episode rules out the diagnosis of major depressive disorder. Copyright ©2019 F.A. Davis Company Predisposing Factors § Biological theories Genetics ‒ Twin and family studies ‒ Other genetic studies Biochemical influences ‒ Possible excess of norepinephrine and dopamine Copyright ©2019 F.A. Davis Company Predisposing factors § § § § The exact etiology of bipolar disorder has yet to be determined. Scientific evidence supports a chemical imbalance in the brain. Theories that consider a combination of hereditary factors and environmental triggers seem to be the most credible. Discuss biological theories of the causes of bipolar disorders. Research suggests that bipolar disorder strongly reflects an underlying genetic vulnerability. Evidence from family, twin, and adoption studies exists to support this observation. Twin studies have indicated a concordance rate for bipolar disorder among monozygotic twins at 60% to 80% compared to 10% to 20% in dizygotic twins. Family studies have shown that, if one parent has a mood disorder, the risk that a child will have a mood disorder is between 10% and 25%. If both parents have the disorder, the risk is two to three times as high. Ongoing genetic research will continue to shed light on the genetic influences in the development of bipolar disorder and the genetic factors that influence response to treatments. Studies have associated symptoms of mania with a functional excess of norepinephrine and dopamine. The neurotransmitter serotonin is believed to remain low in both depression and mania. Acetylcholine is another neurotransmitter believed to be related to bipolar disorder. Although several neurotransmitters have been implicated in influencing symptoms, the cause of bipolar disorder remains unknown. Copyright ©2019 F.A. Davis Company Predisposing Factors (continued_1) § Biological theories (continued) Physiological influences ‒ Brain lesions ‒ Enlarged ventricles ‒ Medication side effects § Neuroanatomical changes have been correlated with dysfunction in the prefrontal cortex, basal ganglia, temporal and frontal lobes of the forebrain, and to parts of the limbic system, including the amygdala, thalamus, and striatum. The different symptoms in bipolar disorder may be correlated to those specific areas of dysfunction. § Certain medications used to treat somatic illnesses have been known to trigger a manic response. The most common of these are the steroids frequently used to treat chronic illnesses such as multiple sclerosis and systemic lupus erythematosus (SLE). Amphetamines, antidepressants, and high doses of anticonvulsants and narcotics also have the potential for initiating a manic episode Copyright ©2019 F.A. Davis Company Predisposing Factors (continued_2) § Psychosocial theories Credibility of psychosocial theories has declined in recent years. Bipolar disorder is viewed as a disease of the brain. Copyright ©2019 F.A. Davis Company Developmental Implications: Childhood and Adolescence § Lifetime prevalence of pediatric and adolescent bipolar disorders is estimated at about 1%. § Diagnosis is difficult. § In the past decade, diagnosis of bipolar I disorder in children and adolescents has rapidly increased to 40 times what it had been historically. It was thought there was a connection between A D H D and the development of bipolar disorder in youth, but research has not supported this. Studies also found that youth who were given this diagnosis more often manifested with a host of atypical symptoms including non-discrete mood episodes, chronic irritability, and temper tantrums. A study of children with non-episodic irritability found that, while these children had a higher risk for anxiety and depression, they were not typically at higher risk for developing bipolar disorder. Copyright ©2019 F.A. Davis Company Developmental Implications: Childhood and Adolescence (continued_1) § Treatment strategies Psychopharmacology ‒ Lithium ‒ Divalproex ‒ Carbamazepine ‒ Atypical antipsychotics § Monotherapy with the traditional mood stabilizers or atypical antipsychotics has historically been the first-line treatment for children. Augmentation with a second medication is indicated when monotherapy fails. § Bipolar disorder in children and adolescents appears to be a chronic condition with a high risk of relapse. Maintenance therapy incorporates the same medications used to treat acute symptoms, although few research studies exist that deal with long-term maintenance of bipolar disorder in children. Copyright ©2019 F.A. Davis Company Developmental Implications: Childhood and Adolescence (continued_2) § Treatment strategies (continued_1) Attention deficit/hyperactivity disorder (A D H D) is the most common comorbid condition. A D H D agents may exacerbate mania and should be administered only after bipolar symptoms have been controlled. Copyright ©2019 F.A. Davis Company Developmental Implications: Childhood and Adolescence (continued_3) § Treatment strategies (continued_2) Family interventions ‒ Psychoeducation about bipolar disorder ‒ Communication training ‒ Problem-solving skills training § Family dynamics and attitudes can play a crucial role in the outcome of a client’s recovery. Interventions with family members must include education that promotes understanding that at least part of the client’s negative behaviors are attributable to an illness that must be managed. § Studies show that family-focused psychoeducational treatment (FFT) is an effective method of reducing relapses and increasing medication adherence in bipolar clients. This is important for adult clients, as well for children and adolescents with bipolar disorder. FFT includes sessions that deal with psychoeducation about bipolar disorder, communication training, and problem-solving skills training. Copyright ©2019 F.A. Davis Company Nursing Process/Assessment § Symptoms may be categorized by degree of severity. § Stage 1. Hypomania: Symptoms not sufficiently severe to cause marked impairment in social or occupational functioning or to require hospitalization Cheerful mood Rapid flow of ideas; heightened perception Increased motor activity Copyright ©2019 F.A. Davis Company Stage 1: hypomania § Symptoms of manic states can be described according to three stages: hypomania, acute mania, and delirious mania. § Describe the symptoms of Stage I: Hypomania. § At this stage, the disturbance is not sufficiently severe to cause marked impairment in social or occupational functioning. The mood of a hypomanic person is cheerful and expansive. There is an underlying irritability that surfaces rapidly when the person’s wishes and desires go unfulfilled. § Perceptions of the self includes ideas of great worth and ability. Thinking is flighty, with a rapid flow of ideas. Perception of the environment is heightened, but the individual is so easily distracted by irrelevant stimuli and goal-directed activities are difficult. § Hypomanic individuals exhibit increased motor activity. They are perceived as being very extroverted and sociable, but they lack the depth of personality and warmth to formulate close friendships. They talk and laugh a great deal, usually very loudly and often inappropriately. Copyright ©2019 F.A. Davis Company Nursing Process/Assessment (continued_1) § Stage 2. Acute mania: Marked impairment in functioning; usually requires hospitalization Elation and euphoria; a continuous “high” Flight of ideas; accelerated, pressured speech Hallucinations and delusions Excessive motor activity Social and sexual inhibition Little need for sleep Copyright ©2019 F.A. Davis Company Stage 2 hypomania § § § § Symptoms of acute mania may be a progression in intensification of those experienced in hypomania, or they may be manifested directly. Most individuals experience marked impairment in functioning and require hospitalization. Acute mania is characterized by euphoria and elation. The person appears to be on a continuous high, but mood is always subject to frequent variation. Cognition and perception become fragmented and often psychotic in acute mania. Accelerated thinking proceeds to racing thoughts, overconnection of ideas, and rapid, abrupt movement from one thought to another. It may be manifested by a continuous flow of accelerated, pressured speech to the point where trying to converse with this individual may be extremely difficult. Attention can be diverted by even the smallest of stimuli. Hallucinations and delusions are common. Psychomotor activity is excessive. Sexual interest is increased. There is poor impulse control, low frustration tolerance, and the individual who is normally discreet may become socially and sexually uninhibited. Energy seems inexhaustible, and the need for sleep is diminished. They may go for many days without sleep and still not feel tired. Hygiene and grooming may be neglected. Dress may be disorganized, flamboyant, or bizarre, and the use of excessive make-up or jewelry is common. Copyright ©2019 F.A. Davis Company Nursing Process/Assessment (continued_2) § Stage 3. Delirious mania: A grave form of the disorder characterized by an intensification of the symptoms associated with acute mania. The condition is rare because the advent of antipsychotic medication. Labile mood; panic anxiety Clouding of consciousness; disorientation Frenzied psychomotor activity Exhaustion and possibly death without intervention Copyright ©2019 F.A. Davis Company Stage 3: delirious mania § § § § § Describe the symptoms of Stage III: Delirious Mania. Delirious mania is a grave form of the disorder characterized by severe clouding of consciousness and an intensification of the symptoms associated with acute mania. The mood of the delirious person is very labile. He or she may exhibit feelings of despair, quickly converting to unrestrained merriment and ecstasy or becoming irritable or totally indifferent to the environment. Cognition and perception are characterized by a clouding of consciousness, with accompanying confusion, disorientation, and sometimes stupor. Other common manifestations include religiosity, delusions of grandeur or persecution, and auditory or visual hallucinations. The individual is extremely distractible and incoherent. Psychomotor activity is frenzied and characterized by agitated, purposeless movements. The safety of these individuals is at stake unless this activity is curtailed. Exhaustion, injury to self or others, and eventually death could occur without intervention. Copyright ©2019 F.A. Davis Company Nursing Diagnosis § Risk for injury related to Extreme hyperactivity, increased agitation, and lack of control over purposeless and potentially injurious movements Copyright ©2019 F.A. Davis Company Nursing Diagnosis (continued_1) § Risk for violence: self-directed or otherdirected related to Manic excitement Delusional thinking Hallucinations Impulsivity Copyright ©2019 F.A. Davis Company Nursing Diagnosis (continued_2) § Imbalanced nutrition less than body requirements related to Refusal or inability to sit still long enough to eat, evidenced by loss of weight, amenorrhea § Disturbed thought processes related to Biochemical alterations in the brain, evidenced by delusions of grandeur and persecution, as well as inaccurate interpretation of the environment Copyright ©2019 F.A. Davis Company Nursing Diagnosis (continued_3) § Disturbed sensory perception related to Biochemical alterations in the brain and to possible sleep deprivation, evidenced by auditory and visual hallucinations § Impaired social interaction related to Egocentric and narcissistic behavior § Insomnia related to Excessive hyperactivity and agitation Copyright ©2019 F.A. Davis Company Clicker Question 2 2. In the initial stages of caring for a client experiencing an acute manic episode, what should the nurse consider to be the priority nursing diagnosis? A. Risk for injury related to excessive hyperactivity B. Disturbed sleep pattern related to manic hyperactivity C. Imbalanced nutrition, less than body requirements, related to inadequate intake D. Situational low self-esteem related to embarrassment secondary to high-risk behaviors Copyright ©2019 F.A. Davis Company Clicker Question Answer 2 Correct Answer: A According to Maslow’s hierarchy of needs, maintaining client safety is always a priority. The impulsiveness and hyperactivity seen in clients diagnosed with acute mania puts them at risk for injury. Copyright ©2019 F.A. Davis Company Criteria for Measuring Outcomes: The Client § Exhibits no evidence of physical injury § Has not harmed self or others § Is no longer exhibiting signs of physical agitation § Eats a well-balanced diet with snacks to prevent weight loss and maintain nutritional status § Verbalizes an accurate interpretation of the environment Copyright ©2019 F.A. Davis Company Criteria for Measuring Outcomes: The Client (continued_1) § Verbalizes that hallucinatory activity has ceased and demonstrates no outward behavior indicating hallucinations § Accepts responsibility for own behaviors § Does not manipulate others for gratification of own needs § Interacts appropriately with others § Is able to fall asleep within 30 minutes of retiring § Is able to sleep 6 to 8 hours per night Copyright ©2019 F.A. Davis Company Planning/Implementation § Risk for Violence: Self-Directed or OtherDirected Remove all dangerous objects from the environment. Maintain a calm attitude. If restraint is deemed necessary, ensure that sufficient staff are available to assist. Copyright ©2019 F.A. Davis Company Planning/Implementation (continued_1) § Impaired Social Interaction Set limits on manipulative behaviors. Do not argue, bargain, or try to reason with the client. Provide positive reinforcement. Goals should include helping the client verbalize inappropriate behaviors, and helping the client demonstrate use of appropriate interaction skills as evidenced by lack of, or marked decrease in, manipulation of others to fulfill own desires. Interventions include setting limits on manipulative behaviors and helping the client recognize that he or she must accept the consequences of their own behaviors Copyright ©2019 F.A. Davis Company Planning/Implementation (continued_2) § Imbalanced Nutrition: Less than Body Requirements / Insomnia Provide client with high-protein, high-calorie foods. Maintain an accurate record of intake, output, and calorie count. Monitor sleep patterns. Copyright ©2019 F.A. Davis Company Patient and Family Education § Nature of the illness Causes of bipolar disorder Cyclic nature of the illness Symptoms of depression Symptoms of mania Copyright ©2019 F.A. Davis Company Patient and Family Education (continued_1) § Management of the illness Medication management Assertive techniques Anger management Copyright ©2019 F.A. Davis Company Patient and Family Education (continued_2) § Support services Crisis hotline Support groups Individual psychotherapy Legal/financial assistance Copyright ©2019 F.A. Davis Company Evaluation § Evaluation of the effectiveness of the nursing interventions is measured by fulfillment of the outcome criteria. Copyright ©2019 F.A. Davis Company Evaluation (continued_1) § Has the client avoided personal injury? § Has violence to the client or others been prevented? § Has agitation subsided? § Have nutritional status and weight been stabilized? § Have delusions and hallucinations ceased? Copyright ©2019 F.A. Davis Company Evaluation (continued_2) § Is the client able to make decisions about own self-care? § Is behavior socially acceptable? § Is the client able to sleep 6 to 8 hours per night and awaken feeling rested? § Does the client understand the importance of maintenance medication therapy? Copyright ©2019 F.A. Davis Company Treatment Modalities for Bipolar Disorder § Individual psychotherapy § Group therapy § Family therapy § Cognitive therapy Copyright ©2019 F.A. Davis Company Treatment modalities for bipolar disorder § § § § § Therapy, whether in a one-on-one environment or with a group, can be beneficial to a client suffering from bipolar disorder. Interpersonal and social rhythm therapy (IPSRT) is a type of therapy specifically designed for bipolar patients. Developed by Frank, the focus of this therapy is helping clients to regulate their social rhythms, or daily activities such as the sleep–wake cycle and exercise routines, that may otherwise disrupt underlying biologic rhythms and contribute to mood disturbances. Once an acute phase of the illness is passed, groups can provide an atmosphere in which individuals may discuss issues in their lives that cause, maintain, or arise out of having a serious affective disorder. Both group psychoeducation and group CBT have demonstrated benefits for this population. The element of peer support may provide a feeling of security, as troublesome or embarrassing issues are discussed and resolved. Self-help groups offer another avenue of support for the individual with bipolar disorder. These groups are usually peer led and are not meant to substitute for, or compete with, professional therapy. The ultimate objectives in working with families of clients with mood disorders are to resolve the symptoms and initiate or restore adaptive family functioning. Some studies with bipolar disorder have shown that behavioral family treatment combined with medication substantially reduces relapse rate compared with medication therapy alone. In cognitive therapy, the individual is taught to control thought distortions that are considered to be a factor in the development and maintenance of mood disorders. The general goals in cognitive therapy are to obtain symptom relief as quickly as possible, to assist the client in identifying dysfunctional patterns of thinking and behaving, and to guide the client to evidence and logic that effectively tests the validity of the dysfunctional thinking. Copyright ©2019 F.A. Davis Company Treatment Modalities for Bipolar Disorder (continued_1) § The Recovery Model Learning how to live a safe, dignified, full, and self-determined life in the face of the enduring disability which may, at times, be associated with serious mental illness. Copyright ©2019 F.A. Davis Company Treatment Modalities for Bipolar Disorder (continued_2) § The Recovery Model (continued_1) In bipolar disorder, recovery is a continuous process. ‒ Client identifies goals. ‒ Client and clinician develop a treatment plan. ‒ Client and clinician work on strategies to help the individual manage the bipolar illness. ‒ Clinician serves as support person to help the individual achieve the previously identified goals. Copyright ©2019 F.A. Davis Company Treatment Modalities for Bipolar Disorder (continued_3) § The Recovery Model (continued_2) Although there is no cure for bipolar disorder, recovery is possible in the sense of learning to prevent and minimize symptoms, and to successfully cope with the effects of the illness on mood, career, and social life. Copyright ©2019 F.A. Davis Company Treatment Modalities for Bipolar Disorder (continued_4) § Electroconvulsive therapy (E C T) Episodes of mania may be treated with E C T when ‒ Client does not tolerate medication. ‒ Client fails to respond to medication. ‒ Client’s life is threatened by dangerous behavior or exhaustion. Copyright ©2019 F.A. Davis Company Psychopharmacology § For mania Lithium carbonate Anticonvulsants Verapamil Antipsychotics § For depressive phase Use antidepressants with care (may trigger mania). Copyright ©2019 F.A. Davis Company Client/Family Education § Lithium Take the medication regularly. Do not skimp on dietary sodium. Drink six to eight glasses of water each day. Notify physician if vomiting or diarrhea occur. Have serum lithium level checked every 1 to 2 months, or as advised by physician. Copyright ©2019 F.A. Davis Company Client/Family Education(continued_1) § Lithium (continued) Notify physician if any of the following symptoms occur: ‒ ‒ ‒ ‒ ‒ ‒ ‒ ‒ Persistent nausea and vomiting Severe diarrhea Ataxia Blurred vision Tinnitus Excessive output of urine Increasing tremors Mental confusion Copyright ©2019 F.A. Davis Company Client/Family Education (continued_2) § Anticonvulsants Refrain from discontinuing the drug abruptly. Report the following symptoms to the physician immediately: skin rash, unusual bleeding, spontaneous bruising, sore throat, fever, malaise, dark urine, and yellow skin or eyes. Avoid using alcohol and over-the-counter medications without approval from physician. Copyright ©2019 F.A. Davis Company Client/Family Education (continued_3) § Verapamil Do not discontinue the drug abruptly. Rise slowly from sitting or lying position to prevent sudden drop in blood pressure. Report the following symptoms to physician: ‒ ‒ ‒ ‒ ‒ Irregular heartbeat; chest pain Shortness of breath; pronounced dizziness Swelling of hands and feet Profound mood swings Severe and persistent headache Copyright ©2019 F.A. Davis Company Client/Family Education (continued_4) § Antipsychotics Do not discontinue drug abruptly. Use sunblock when outdoors. Rise slowly from a sitting or lying position. Avoid alcohol and over-the-counter medications. Continue to take the medication, even if feeling well and as though it is not needed; symptoms may return if medication is discontinued. Copyright ©2019 F.A. Davis Company Client/Family Education (continued_5) § Antipsychotics (continued) Report the following symptoms to physician: ‒ Sore throat; fever; malaise, unusual bleeding; easy bruising; skin rash, persistent nausea and vomiting ‒ Severe headache; rapid heart rate, difficulty urinating or excessive urination, muscle twitching, tremors ‒ Darkly colored urine; pale stools ‒ Yellow skin or eyes ‒ Excessive thirst or hunger ‒ Muscular incoordination or weakness Copyright ©2019 F.A. Davis Company Clicker Question 3 3. A client who is prescribed lithium carbonate is being discharged from inpatient care. Which medication information should the nurse teach this client? A. Do not skimp on dietary sodium intake. B. Have serum lithium levels checked every 6 months. C. Limit fluid intake to 1000 milliliter of fluid per day. D. Adjust the dose if you feel out of control. Copyright ©2019 F.A. Davis Company Clicker Question Answer 3 Correct Answer: A Clients taking lithium should consume a diet adequate in sodium and drink 2,500 to 3,000 milliliter of fluid per day. Lithium is a salt and competes in the body with sodium. If sodium is lost, the body will retain lithium with resulting toxicity. Maintaining normal sodium and fluid levels is critical to maintaining therapeutic levels of lithium and preventing toxicity. Copyright ©2019 F.A. Davis Company