How to Include Patients' Family in BD-I Treatment Plan

In part 1 of this video, Erin Walczykowski, APRN, PMHNP-BC, MBI Health Services, LLC, Washington DC, explains what a bipolar disorder 1 (BD-I) diagnosis means for the patient and their family, and how clinicians can include family and support into a BD-I treatment plan.

In part 2, Walcyzkowski answers:

• What advice do you have for clinicians prescribing medications to patients with bipolar disorder for the first time?
• How can patients and families be educated on the importance of adherence?

In the upcoming part 2, she discusses:

• Are there any new medications or treatments coming down the pipeline that clinicians should keep an eye on?
• Any final thoughts or common misconceptions on this topic that you would like to clear up?

Erin Walczykowski, APRN, PMHNP-BC, is a board-certified mental health nurse practitioner and registered nurse serving community health patients in Washington, D.C.

Read the transcript:

Hello, my name is Erin Walcykowski. I am a psychiatric nurse practitioner practicing out of Washington, DC. I currently practice within community mental health, specifically on an ACT team, which is assertive community treatment. So I see individuals with chronic and persistent mental illness.

A bipolar disorder or bipolar I diagnosis means a lot for patient and their family. I would like to say that you get a bipolar diagnosis, specifically bipolar I, it's a change, a huge change in their life. It means there's going to potentially be an emotional rollercoaster. There's going to be ups, there's going to be downs. There is going to be a need for a plan. There's going to be a need for a team approach.

There's going to be a need for support. There are going to be challenges. There's going to need to be adjustments, all those things that need to be considered for this individual, so it is a key point in their life but it's also a moment where you can provide education, you can provide support, you can be an individual that's a part of their team, their family. You almost become a part of their family to an extent.

The bipolar I diagnosis is a major change for their life. You want them to understand that this is something that is important for them to learn about, to grasp, to be a part of their treatment plan, to be a part of an active participant in their life. They're going to have to plan a lot of things, have a lot of foresight about a lot of what's going to happen in their life, certain events, certain things they want to do, what they're seeing, what they're experiencing, what they're feeling.

For their family, even more important that they are the eyes and ears. They have a loved one and they've been given this diagnosis. What do you know about your family member? What do you know about your loved one? How are they when they are "normal?" What is their usual, what is their normal baseline? What do they look like when they deviate from that? How are you able to see the red flags? What are the red flags? What are the green flags? How do you know you're going in the right direction, in a good direction? They're improving. How do you know they're decompensating?

How can you engage this loved one and family member to be able to express to you how they're feeling, what they're noticing, how can you help them gain a certain level of insight at all, if possible? How are you able to intervene as a family member? What does this mean for you in terms of maintaining that relationship with your loved one? Bipolar I diagnosis can a lot of times mean frustration. It can mean that you are sometimes going to be either upset with your family member, because they are not who you know them to be, or who you want them to be. And maybe you're upset with yourself because the limitations and how you can help. So it's just a change. It's a huge change in that person's life for the individual, for the patient, and for the family.

Clinicians can include family support in the treatment of bipolar I disorder in a variety of ways. Based on my clinical experience, there are various different factors to take into consideration when you're wanting to include the family. Bring them on board, include them as part of the team.

The various ways that I like to do this is I like to bring them in on different treatment team meetings. If you have a patient that has an appointment with you, you can always invite them or tell them, "Hey, do you have a loved one you would like to bring with you, your husband, wife, partner, mother, father, brother, sister, a close friend?" You always want to welcome any individual that's close to them, that is familiar with them, that they feel comfortable with, that they feel like, "Okay, this is someone I trust and care for and I know they care about me."

You always just want to extend that to say, "Hey, I'm here to help you as the patient," but your patient includes the family. The patient includes close friends, it includes their team that they already have. So I always just extend that to them to say, "Whenever you come see me for a visit, you're welcome to bring whoever you think would be helpful," because that's helpful in terms of getting additional data, additional information, particularly if the patient can't recall history very well, did not or does not have a good level of insight.

Sometimes the family can provide a good amount of information that helps you clinically get a clearer idea of the picture, of what's going on with the patient. I include them in terms of providing resources, lists, whether that's list of symptoms, lists of resources, places they can call, websites they can go to get more education on what does a Bipolar disorder I diagnosis look like, what does that entail? What do the symptoms look like?

Showing them videos. Videos online, videos of other patients or clients, so that they can get a sense of what this could look like, giving them different websites to go to so they could read, printouts, pamphlets, printouts, you give that to them. Numbers to call, whether you want them to reach out to different support groups because sometimes, families and patients do well when they are hearing this from other individuals that are going through this, just like them.

I try to include them in support in terms of phone check-ins. How often are you in touch with the patient? I know for example, for myself, on average, I'm going to see a patient at least once a month, but if they have Bipolar I disorder, depending on if they're in a depressive phase, or if they're in a manic phase, that might dictate do I need to see them more often?

Do I need to see them every two weeks? Do I need to see them every week? Does their treatment team, the social workers, the case managers, they need to be seeing them multiple times a week. Do they need to reach out? Do they need to call? Do they need to do phone check-ins? Letting them know, "Hey, we will be calling. We will be reaching out. We might be stopping by to say hey." You want eyes and ears on the patient. And you want to engage the family so that they don't feel like they're out there alone, that if they have questions, if they have concerns, if they're confused about anything, uncertain, they have individuals that they can call on. They have the provider myself, again, they might have a team of individuals they can reach out to. So it helps them to feel supported.

So that's another way, providing phone calls, check ins, supporting them through what could be ultimately is that challenge of when the patient isn't doing well and they're not themselves, how do they view the family members helping out? Is there resentment? Is there anger there? Is there pushback?

So they have again, more individuals on board that can help drive the treatment in the right direction, including them in just different routines. Like, "Hey, these are suggestions we might have for you in terms of setting up specific routines," whether that's to get a patient back on track, in terms of whether they're manic, whether they're experiencing depression, how can we get them back on track if they're doing well and we're in a maintenance phase? How do we best keep them there? What things do we need to be mindful of?

What day-to-day things are best for the patient to keep a routine, to lower the risk that they'll experience certain stressors or have things happen in their daily life that might throw them off track? If they're let's say for example, in a manic phase, how do we include the family on what they can do? Do they need to for example, hold the patient's credit card so that they don't overspend? Do they need to watch the patient take meds, actually watch them on a consistent basis to make sure they're not missing any dosages? Things like that are very important.

Is there a childcare plan? If the patient has young ones and they are not doing well, is there plan in place to where the family or somebody could step in and provide some childcare if the patient is unable to safely do so? Involving the family in terms of if this affects the patient's job, do they need to take some time off from work? How is the family able to step in and provide support there?

Do I need to do FMLA paperwork? Do I need to engage with the family about that? Hey, how much time is needed do we think to provide care to this patient? How much time do you need in order to be there as their primary support, to help them to appointments, to monitor them, to make adjustments at home? These are all things that we have to consider in sharing a safe setting. Does the family know about okay, if a client is suicidal or impulsive, how can we set up the home environment to ensure that these individuals or that their family/loved ones will stay safe? And I would say also, probably one of the key things too like I said before, involving the family, you get history.

And including them in the process and highlighting the importance of documentation. As we go through this process, knowing what medications the client took, when, what was the outcome? Did it work? Did it not work? What side effects, what symptoms were exhibited when they went in the hospital or did not? So that we know the patterns and we can track it. It's also really helpful too if the patient has to go from an outpatient treatment setting to an inpatient setting, and inpatient providers need as much information as possible, this is really helpful to have that documentation on hand that the family can say, "Here, we know what medications they took. We know what periods or episodes they had, what it looked like, what helped, what didn't help, what exacerbated it."

And it's also helpful too that if you're treating a client for a while and then for whatever reason, they may need to transition onto a new provider, continuity of care, that information can get passed along versus you have a client come in, they're not able to really give you much details as to their psychiatric history, and sometimes the family might not be able to as well. So this I think really does help with that process.