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Goals of Psychiatric Management
maintain a therapeutic alliance.
Monitor the patient's psychiatric
Provide education regarding bipolar disorder.
Enhance treatment adherence.
Promote regular patterns of activity and
Identify new episodes early.
Minimize functional impairments.
the presence of an alcohol or substance use disorder or other factors
that may contribute to the disease process or complicate its treatment.
conditions commonly associated with secondary mania are multiple
sclerosis and lesions involving right-sided subcortical structures
or cortical areas closely linked to the limbic system.
l-Dopa and corticosteroids are the most
common medications associated with secondary mania.
Substance use may precipitate mood episodes.
Patients may also use substances to ameliorate the symptoms of such
Inquire about a history of time periods
with mood dysregulation or lability accompanied by associated manic
symptoms (e.g., decreased sleep).
commonly presents with depressive symptoms.
Patients rarely volunteer information about
manic or hypomanic symptoms.
of the patient's risk for suicide is critical; lifetime
rates of completed suicide for people with bipolar disorder are
as high as 10% to 15%.
The overwhelming majority of suicide attempts
are associated with depressive episodes or depressive features during
Ask every patient about suicidal ideation,
intention to act on these ideas, and extent of plans or preparation
Collect collateral information from family
members or others.
Assess for access to means of committing
suicide (e.g., medications, firearms) and the lethality of these
Assess for factors associated with increased
risk, such as agitation, pervasive insomnia, impulsiveness, or other
psychiatric comorbidity such as substance abuse, psychosis (especially
with command hallucinations), or personality disorder.
Assess for family history of suicide and
history of recent exposure to suicide.
Consider the nature and potential lethality
of any prior suicide attempts.
Closely monitor patients who exhibit suicidal
or violent ideas or intent.
Carefully document the decision-making
Consider hospitalization for patients
pose a serious
threat of harm to themselves or others,
are severely ill and lack adequate social
support outside a hospital setting or demonstrate significantly
have complicating psychiatric or general
medical conditions, or
have not responded adequately to outpatient
Reevaluate the treatment setting on an
ongoing basis to determine whether it is optimal or whether the
patient would benefit more from a different level of care.
Provide a calm and highly structured environment.
Consider limiting access to cars, credit
cards, bank accounts, or telephones and cellular phones during the
manic phase because of the risk of reckless behavior.
alliance is critical for understanding and managing the individual
Over time, knowledge gained about the patient
and the illness course allows early identification of usual prodromal
symptoms and early recognition of new episodes.
especially important during manic episodes, when patient insight
is often limited or absent.
Be aware that small changes in mood or behavior
may herald the onset of an episode.
Be aware that,
over time, patients will vary in their ability to understand and
retain information and accept and adapt to the need for long-term
Education should be an ongoing process in
which the psychiatrist gradually but persistently introduces facts
about the illness and its treatment.
Printed and Internet material (e.g., from
http://www.psych.org) can be helpful.
Use similar educational approaches for family
members and significant others.
about treatment is often expressed as poor adherence to medication
or other treatments.
Causes of ambivalence include
- lack of insight about
having a serious illness and
- reluctance to give up the experience of hypomania
Medication side effects, cost, and other
demands of long-term treatment may be burdensome and need to be
Many side effects can be corrected with
careful attention to dosing, scheduling, and medication formulation
(e.g., sustained release, liquid).
precede episodes in all phases of the illness.
Social rhythm disruption with disrupted
sleep-wake cycles may specifically trigger manic episodes.
Patients and their families should be informed
about the potential effects of sleep disruption in triggering manic
Regular patterns for daily activities should
be promoted, including sleeping, eating, physical activity, and
social and emotional stimulation.
should help the patient, family members, and significant others
recognize early signs and symptoms of manic or depressive episodes.
Early markers of episode onset are often
predictable across episodes for an individual patient.
Early identification of a prodrome is facilitated
by the psychiatrist's consistent relationship with the
patient as well as with the patient's family.
and address impairments in functioning.
Assist the patient
in scheduling absences from work or other responsibilities.
Encourage the patient to avoid major life
changes while in a depressive or manic state.
Assess and address the needs of children
of patients with bipolar disorder.