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Bipolar Disorder, Emergency Medicine

Basics

Description

- Full extent of pathology often revealed only by outside informants - Onset gradual or acute, duration several weeks or months; rarely may be chronic

- Bipolar disorder: - Formerly manic depressive disorder - Defined as one or more episodes of hypomanic, manic, or mixed mood - Possibly with episodes of depressed mood - Bipolar II is used to denote cases where hypomania has occurred in the course of the disorder but never mania. - Typically begins in the teens or 20s - Episodes of abnormal mood may be mild or severe, brief or prolonged, infrequent or chronic, chiefly elevated or chiefly depressed in character. - Bipolar disorder may be readily responsive to treatment or nearly intractable.

- Psychiatric history: - Recent symptoms of mania (often collateral sources critical): Elevated, expansive, or irritable mood; increased energy and activity; decreased need for sleep; irresponsibility, disregard for negative consequences of actions; talkativeness; distractibility; fast thoughts; grandiosity, overconfidence - Past mania or depression - Noncompliance with mood stabilizer - Recent initiation or discontinuation of antidepressant - Recent substance abuse - Bipolar family history

- Affect: - Irritable, argumentative, often multiple recent arguments or fights - Less commonly euphoric or expansive - Often labile with depressed or tearful intervals (may confound diagnosis) - Patient likely to describe mood as tense, irritable, or depressed rather than euphoric

- Lamotrigine must be started by a gradual dose escalation schedule specified by manufacturer to avoid increased risk of severe dermatologic reactions; if resumed after discontinuation for more than 5 half-lives (about 5 days), the gradual dose escalation schedule must be used again (half-life is shorter with certain antiepileptics, OCPs, rifampin; see prescribing literature). - Lithium: 600-3,000 mg/d (often in div. doses or in sustained-release dose forms; in acute mania, initiate at 300 mg PO TID) - Olanzapine: 1.25-30 mg/d, QHS or in div. doses - Perphenazine: 4-32 mg/d PO QHS or in div. doses - Quetiapine: 50-400 mg PO QHS or 100-400 PO BID; quetiapine XR PO 50-800 mg QHS - Risperidone: 0.5-6 mg/d PO QHS or in div. doses - Valproate (e.g., Depakote): 750-3,000 mg/d (often in div. doses; in acute mania, initiate at 250 mg PO TID)

- Involuntary hospitalization is required by danger to self: - Suicidal risk, especially if mixed or labile mood or psychotic - Unsafe behaviors due to impaired judgment - Medically unstable - Hospitalization diagnostically required

  • Mania:Presentation is diverse and may be difficult to recognize as mania:Simple irritabilityCheerfulnessPsychosisDeliriumAgitationFull extent of pathology often revealed only by outside informantsOnset gradual or acute, duration several weeks or months; rarely may be chronic
  • Hypomania:Milder symptoms without marked impairment
  • Mixed mood:Simultaneous symptoms of mania and depressionTreat in ED as for mania
  • Bipolar disorder:Formerly manic depressive disorderDefined as one or more episodes of hypomanic, manic, or mixed moodPossibly with episodes of depressed moodBipolar II is used to denote cases where hypomania has occurred in the course of the disorder but never mania.Typically begins in the teens or 20sEpisodes of abnormal mood may be mild or severe, brief or prolonged, infrequent or chronic, chiefly elevated or chiefly depressed in character.Bipolar disorder may be readily responsive to treatment or nearly intractable.
  • Schizoaffective disorder:Characterized by episodes of altered mood, but psychotic features present even when mood is normal

Etiology

  • Typically, a primary psychiatric disorder, with genetic association
  • May be secondary to medical disorder (e.g., drug toxicity, endocrine, neurologic process)
  • Particularly likely to be secondary if1st episodepatient >40 yratypical or mixed presentationabnormal sensorium

Diagnosis

Signs and Symptoms

History

  • Psychiatric history:Recent symptoms of mania (often collateral sources critical): Elevated, expansive, or irritable mood; increased energy and activity; decreased need for sleep; irresponsibility, disregard for negative consequences of actions; talkativeness; distractibility; fast thoughts; grandiosity, overconfidencePast mania or depressionNoncompliance with mood stabilizerRecent initiation or discontinuation of antidepressantRecent substance abuseBipolar family history
  • Medical history:Endocrine, metabolic, or neurologic disordersCurrent or recent medications

Physical Exam

  • Appearance:Hyperactive, if not agitatedTalkative, often with loud, rapid, or "pressured"¯ speech
  • Affect:Irritable, argumentative, often multiple recent arguments or fightsLess commonly euphoric or expansiveOften labile with depressed or tearful intervals (may confound diagnosis)Patient likely to describe mood as tense, irritable, or depressed rather than euphoric
  • Neurovegetative:Increased energy, engaged in multiple goal-directed activities many hours per dayRacing thoughtsDecreased sleep
  • Thought process:Rapid, distractible, may be incoherent, delirious
  • Thought content:Psychosis possible, either mood congruent (e.g., delusions of grandeur or power) or mood incongruent (may be indistinguishable from other psychotic disorders)
  • Judgment:Inflated self-esteem, perhaps to grandiose or psychotic extentUncharacteristic, irresponsible behavior, such as financial or sexual indiscretions, with inability to recognize negative consequences of actions.Substance abuse is frequent during mania.
  • Sensorium:Typically normalConfusion or delirium possible

Essential Workup

  • Physical and neurologic exam; vital signs
  • Mania may present as delirium and need workup of full differential diagnosis of delirium.

Diagnosis Tests & Interpretation

Lab

  • Toxicology screen (urine or serum)
  • Blood alcohol level
  • Electrolytes
  • Blood glucose
  • CBC
  • TSH
  • Lithium, carbamazepine, valproate serum levels, if relevant
  • Other tests as suggested by history or physical exam

Imaging

CT head only with suspicion of neurologic etiology

Differential Diagnosis

  • Primary mania of bipolar or schizoaffective disorder
  • Psychosis
  • Agitated depression
  • Personality disorders:BorderlineNarcissisticAntisocial
  • Attention deficit disorder
  • Conduct or intermittent explosive disorders
  • Organic brain syndrome
  • Intoxication or withdrawal from alcohol or sedative hypnotics
  • Intoxication with cocaine, amphetamines, phencyclidine, or other sympathomimetics
  • Accidental or deliberate toxic overdose
  • Treatment with antidepressants or electroshock therapy in susceptible individuals
  • Recent discontinuation of antidepressant medication
  • Corticosteroid or thyroid hormones
  • Anticholinergics
  • Treatment of Parkinson disease
  • Cyclobenzaprine (Flexeril)
  • Endocrine or metabolic disorders (particularly thyroid disease)
  • Encephalitis
  • Meningitis
  • Postictal states
  • MS
  • Postcerebrovascular accident
  • CNS tumors
  • CNS vasculitis
  • General paresis

Treatment

Initial Stabilization/Therapy

  • High violence potential:Quiet environmentPrompt evaluationNonconfrontational mannerAdequate security backupPhysical restraint and sedation, as needed
  • For cooperative, but agitated patient:PO neuroleptics (e.g., haloperidol, consider olanzapine or chlorpromazine as alternate) or PO benzodiazepines (e.g., lorazepam)
  • For uncooperative agitated patient:Synergistic combination of IM, IV, or PO haloperidol and lorazepam widely used (some authorities favor monotherapy with benzodiazepine or neuroleptic):Benztropine for prevention of acute dystonic reaction to haloperidol is not usually required when concurrent benzodiazepine is given.Consider lorazepam, olanzapine, ziprasidone, or chlorpromazine IM as alternative.

Ed Treatment/Procedures

  • Outpatient management:Neuroleptics for symptomatic treatment, on temporary or continuing basisAgents for sleepDiscontinuation of antidepressant if related to present hypomania or maniaInitiation or restart of mood-stabilizer therapy:Action of mood-stabilizing agents requires days or weeks, even after full serum level attained.
  • Inpatient management:Sedation or initiation of mood stabilizer in consultation with admitting psychiatrist

Medication

  • Acute agitation:Lorazepam: 2 mg PO/IM (lower dose in mild agitation or in frail or elderly); may repeat q30min, generally not to exceed 12 mg/24hHaloperidol: 5 mg PO (lower dose in mild agitation or in frail or elderly); may repeat q30min, generally not to exceed 20 mg/24hSynergistic combination of haloperidol, 5 mg IM/IV/PO + lorazepam 1-2 mg IM/IV/PO, repeat q30min, as required (doses may be smaller in elderly or frail patients)Olanzapine 10 mg IM, ziprasidone 10 mg IM, aripiprazole 9.75 mg IM or chlorpromazine 50 mg IM may be useful parenteral alternatives, perhaps at a lower dose in frail or elderly (avoid chlorpromazine in hypotension; ziprasidone may have more QT prolonging effect than other neuroleptics but the clinical relevance of such effect at this dose is unclear).
  • Typical outpatient medications:Aripiprazole: 5-20 mg PO QDBenztropine: 1 mg PO BIDCarbamazepine: 400-2,000 mg/d (often in div. doses or in sustained-release dose forms)Clonazepam: 0.5-2 mg PO QHS or 0.5-2 mg PO BIDHaloperidol: 0.5-5 mg PO BIDLamotrigine: 25-200 mg/d in 1 or 2 div. doses (typically up to 100 mg/d in patients taking valproate, up to 500 mg/d in patients taking carbamazepine or certain other cytochrome inducers, but not valproate)
  • Lamotrigine must be started by a gradual dose escalation schedule specified by manufacturer to avoid increased risk of severe dermatologic reactions; if resumed after discontinuation for more than 5 half-lives (about 5 days), the gradual dose escalation schedule must be used again (half-life is shorter with certain antiepileptics, OCPs, rifampin; see prescribing literature).Lithium: 600-3,000 mg/d (often in div. doses or in sustained-release dose forms; in acute mania, initiate at 300 mg PO TID)Olanzapine: 1.25-30 mg/d, QHS or in div. dosesPerphenazine: 4-32 mg/d PO QHS or in div. dosesQuetiapine: 50-400 mg PO QHS or 100-400 PO BID; quetiapine XR PO 50-800 mg QHSRisperidone: 0.5-6 mg/d PO QHS or in div. dosesValproate (e.g., Depakote): 750-3,000 mg/d (often in div. doses; in acute mania, initiate at 250 mg PO TID)

The safety of psychotropic medications in pregnancy is a complex issue: Lithium, valproate, and carbamazepine are Pregnancy Category D and pose particular risks, highest in early pregnancy.

Follow-Up

Disposition

Admission Criteria

  • Involuntary hospitalization is required by danger to self:Suicidal risk, especially if mixed or labile mood or psychoticUnsafe behaviors due to impaired judgmentMedically unstableHospitalization diagnostically required
  • Involuntary hospitalization also required by:Risk of behaviors dangerous to othersInability to care for self (unable to obtain basic needs, such as food, clothing, or shelter)

Discharge Criteria

  • Patients with mild symptoms may be discharged on medications noted above if:necessary supports to ensure safety are in place.patient is compliant with treatment plan.consultation with outpatient psychiatrist is available within 1-3 days.
  • Some patients who are not legally committable may refuse treatment; explain availability of future treatment to patient and any involved friends or family.

Pearls and Pitfalls

  • Manic patients are more likely to appear dysphoric or irritable, rather than "happy."¯
  • Patients presenting with depression should be asked about features suggesting mania and hypomania; 70% of bipolar patients have previously been misdiagnosed.
  • Individuals with bipolar disorder are at high risk for addiction, further complicating treatment.
  • Prompt recognition of the earliest signs of mania may allow prevention of a full episode.
  • Bipolar disorder in children frequently manifests as behavioral disinhibition or irritability.

Additional Reading

  • Anderson IM, Haddad PM, Scott J. Bipolar disorder. BMJ. 2012;345:e8508.
  • Lukens TW, Wolf SJ, Edlow JA, et al. Clinical policy: Critical issues in the diagnosis and management of the adult psychiatric patient in an emergency department. Ann Emerg Med. 2006;47(1):79-99.
  • Sachs GS, Dupuy JM, Wittman CW. The pharmacologic treatment of bipolar disorder. J Clin Psychiatry. 2011;72(5):704-715.

See Also (Topic, Algorithm, Electronic Media Element)

(Topic, Algorithm, Electronic Media Element) Medical vs. Psychiatric

  • Delirium
  • Depression
  • Dystonic Reaction
  • Psychiatric Commitment
  • Psychosis, Acute
  • Psychosis, Medical vs. Psychiatric

Codes

ICD9

  • 296.00 Manic disorder, single episode, unspecified degree
  • 296.50 Bipolar affective disorder, depressed, unspecified degree
  • 296.80 Bipolar disorder, unspecified
  • 296.60 Bipolar affective disorder, mixed, unspecified degree
  • 296.01 Bipolar I disorder, single manic episode, mild
  • 296.02 Bipolar I disorder, single manic episode, moderate
  • 296.03 Bipolar I disorder, single manic episode, severe, without mention of psychotic behavior
  • 296.04 Bipolar I disorder, single manic episode, severe, specified as with psychotic behavior
  • 296.40 Bipolar affective disorder, manic, unspecified degree
  • 296.41 Bipolar I disorder, most recent episode (or current) manic, mild
  • 296.42 Bipolar I disorder, most recent episode (or current) manic, moderate
  • 296.43 Bipolar I disorder, most recent episode (or current) manic, severe, without mention of psychotic behavior
  • 296.44 Bipolar I disorder, most recent episode (or current) manic, severe, specified as with psychotic behavior
  • 296.51 Bipolar I disorder, most recent episode (or current) depressed, mild
  • 296.52 Bipolar I disorder, most recent episode (or current) depressed, moderate
  • 296.53 Bipolar I disorder, most recent episode (or current) depressed, severe, without mention of psychotic behavior
  • 296.54 Bipolar I disorder, most recent episode (or current) depressed, severe, specified as with psychotic behavior
  • 296.61 Bipolar I disorder, most recent episode (or current) mixed, mild
  • 296.62 Bipolar I disorder, most recent episode (or current) mixed, moderate
  • 296.64 Bipolar I disorder, most recent episode (or current) mixed, severe, specified as with psychotic behavior
  • 296.7 Bipolar I disorder, most recent episode (or current) unspecified
  • 296.81 Atypical manic disorder
  • 296.82 Atypical depressive disorder
  • 296.89 Other bipolar disorders
  • 296.8 Other and unspecified bipolar disorders

ICD10

  • F31.9 Bipolar disorder, unspecified
  • F31.10 Bipolar disorder, current episode manic without psychotic features, unspecified
  • F31.30 Bipolar disord, crnt epsd depress, mild or mod severt, unsp
  • F31.81 Bipolar II disorder
  • F31.0 Bipolar disorder, current episode hypomanic
  • F31.11 Bipolar disord, crnt episode manic w/o psych features, mild
  • F31.12 Bipolar disord, crnt episode manic w/o psych features, mod
  • F31.13 Bipolar disord, crnt epsd manic w/o psych features, severe
  • F31.1 Bipolar disorder, current episode manic w/o psych features
  • F31.2 Bipolar disord, crnt episode manic severe w psych features
  • F31.31 Bipolar disorder, current episode depressed, mild
  • F31.32 Bipolar disorder, current episode depressed, moderate
  • F31.3 Bipolar disord, current episode depress, mild or mod severt
  • F31.4 Bipolar disord, crnt epsd depress, sev, w/o psych features
  • F31.5 Bipolar disord, crnt epsd depress, severe, w psych features
  • F31.60 Bipolar disorder, current episode mixed, unspecified
  • F31.61 Bipolar disorder, current episode mixed, mild
  • F31.62 Bipolar disorder, current episode mixed, moderate
  • F31.63 Bipolar disord, crnt epsd mixed, severe, w/o psych features
  • F31.64 Bipolar disord, crnt episode mixed, severe, w psych features
  • F31.6 Bipolar disorder, current episode mixed
  • F31.89 Other bipolar disorder
  • F31.8 Other bipolar disorders

SNOMED

  • 13746004 Bipolar disorder (disorder)
  • 191618007 Bipolar affective disorder current episode manic (disorder)
  • 191627008 Bipolar affective disorder current episode depression (disorder)
  • 83225003 Bipolar II disorder
  • 191636007 mixed bipolar affective disorder (disorder)
  • 31446002 Bipolar I disorder, most recent episode hypomanic (disorder)
  • 371596008 bipolar I disorder (disorder)