Bipolar Disorder, Emergency Medicine

Basics

Description

Mania:
- Presentation is diverse and may be difficult to recognize as mania:
  - Simple irritability
  - Cheerfulness
  - Psychosis
  - Delirium
  - Agitation
- Full extent of pathology often revealed only by outside informants
- Onset 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 depression
- Treat in ED as for mania
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.
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 if
- 1st episode
- patient >40 yr
- atypical or mixed presentation
- abnormal 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, overconfidence
- Past mania or depression
- Noncompliance with mood stabilizer
- Recent initiation or discontinuation of antidepressant
- Recent substance abuse
- Bipolar family history
Medical history:
- Endocrine, metabolic, or neurologic disorders
- Current or recent medications

Physical Exam

Appearance:
- Hyperactive, if not agitated
- Talkative, often with loud, rapid, or "pressured"¯ speech
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
Neurovegetative:
- Increased energy, engaged in multiple goal-directed activities many hours per day
- Racing thoughts
- Decreased 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 extent
- Uncharacteristic, irresponsible behavior, such as financial or sexual indiscretions, with inability to recognize negative consequences of actions.
- Substance abuse is frequent during mania.
Sensorium:
- Typically normal
- Confusion 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:
- Borderline
- Narcissistic
- Antisocial
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 environment
- Prompt evaluation
- Nonconfrontational manner
- Adequate security backup
- Physical 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 basis
- Agents for sleep
- Discontinuation of antidepressant if related to present hypomania or mania
- Initiation 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/24h
- Haloperidol: 5 mg PO (lower dose in mild agitation or in frail or elderly); may repeat q30min, generally not to exceed 20 mg/24h
- Synergistic 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 QD
- Benztropine: 1 mg PO BID
- Carbamazepine: 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 BID
- Haloperidol: 0.5-5 mg PO BID
- Lamotrigine: 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. 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)

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 psychotic
- Unsafe behaviors due to impaired judgment
- Medically unstable
- Hospitalization diagnostically required
Involuntary hospitalization also required by:
- Risk of behaviors dangerous to others
- Inability 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.

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)

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