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  • Goals of Psychiatric Management

    • Establish and maintain a therapeutic alliance.

    • Monitor the patient's psychiatric status.

    • Provide education regarding bipolar disorder.

    • Enhance treatment adherence.

    • Promote regular patterns of activity and sleep.

    • Anticipate stressors.

    • Identify new episodes early.

    • Minimize functional impairments.

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1. Perform a diagnostic evaluation.

  • Assess for the presence of an alcohol or substance use disorder or other factors that may contribute to the disease process or complicate its treatment.

    • Neurological 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 episodes.

  • Inquire about a history of time periods with mood dysregulation or lability accompanied by associated manic symptoms (e.g., decreased sleep).

    • Bipolar disorder commonly presents with depressive symptoms.

    • Patients rarely volunteer information about manic or hypomanic symptoms.

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2. Ensure the safety of the patient and others and determine a treatment setting.

  • Evaluate safety.

    • Careful assessment 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 mixed episodes.

    • Ask every patient about suicidal ideation, intention to act on these ideas, and extent of plans or preparation for suicide.

    • 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 means.

    • 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 process.

  • Consider hospitalization for patients who

    • 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 impaired judgment,

    • have complicating psychiatric or general medical conditions, or

    • have not responded adequately to outpatient treatment.

  • 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.

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3. Establish and maintain a therapeutic alliance.

  • A therapeutic alliance is critical for understanding and managing the individual patient.

  • Over time, knowledge gained about the patient and the illness course allows early identification of usual prodromal symptoms and early recognition of new episodes.

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4. Monitor the patient's psychiatric status.

  • Monitoring is 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.

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5. Educate the patient and his or her family.

  • 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 treatment.

  • 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.

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6. Enhance treatment adherence.

  • Ambivalence 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 or mania.

  • Medication side effects, cost, and other demands of long-term treatment may be burdensome and need to be discussed.

  • Many side effects can be corrected with careful attention to dosing, scheduling, and medication formulation (e.g., sustained release, liquid).

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7. Promote awareness of stressors and regular patterns of activity and sleep.

  • Stressors commonly 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 episodes.

  • Regular patterns for daily activities should be promoted, including sleeping, eating, physical activity, and social and emotional stimulation.

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8. Work with the patient to anticipate and address early signs of relapse.

  • The psychiatrist 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.

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9. Evaluate and manage functional impairments.

  • Identify 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.

References

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Related Content
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The American Psychiatric Publishing Textbook of Psychiatry, 5th Edition > Chapter 22.  >
Gabbard's Treatments of Psychiatric Disorders, 4th Edition > Chapter 56.  >
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The American Psychiatric Publishing Textbook of Psychiatry, 6th Edition > Chapter 19.  >
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'Hypnotic' prescription patterns in a large managed-care population. Sleep Med 2004;5(5):463-6.doi:10.1016/j.sleep.2004.03.007.
 
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