• 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.


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.


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.


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.


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.


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.


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).


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.


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.


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.


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