Bipolar disorder

Background

• Mental disorder characterized by periods of elevated moods and periods of depression
• Spectrum of disorders including Bipolar Type I, Bipolar Type II, and Bipolar NOS

Clinical Features

Manic Episode

• Abnormally and persistently elevated, expansive, or irritable mood lasting at least 1 week
• At least 3 of the following symptoms (4 if only irritable)
  • Inflated self esteem or grandiosity
  • Decreased need for sleep
  • More talkative/pressured speech
  • Flight of ideas/racing thoughts
  • Easily distracted
  • Increase in goal-directed activity or psychomotor agitation
  • Involvement in high pleasure, high risk activities
    • Gambling, shopping sprees, sexual indiscretions
• Sufficient to cause impairment in functioning, relationships, or hospitalization
• Not as a result of substance abuse or medical condition (e.g. hyperthyroid)

Hypomanic Episode

• Same features as manic episode however less intense
• Symptoms only need to persist for 4 days

Major Depressive Episode

• Sleep - increased or decreased

• Interest - losing interest or pleasure in activities

• Guilt - excessive guilt

• Energy - feels of fatigue, low energy

• Concentration - cognitive decine, indecisiveness

• Appetite - weight loss/gain

• Psychomotor agitation or depression

• Suicidal ideation

Must have 5 symptoms in a 2 week period including depressed mood and loss of interest

Mixed Episode

• Fulfill features of both manic and major depressive episode
• Must last at least 1 week

Differential Diagnosis

General Psychiatric

• Organic causes
  • Delirium
  • Dementia
  • Overdose
• Psychiatric causes
  • Depression
  • Anxiety
  • Conversion disorder
  • Bipolar disorder
  • Acute psychosis
  • Panic attack
  • Schizophrenia

Evaluation

• Usually will not be diagnosed in the emergency department
• Needs evaluation by a psychiatrist

Bipolar I

• Meets criteria for one manic or mixed episode
• Symptoms cause social/occupational distress or impairment

Bipolar II

• Meets criteria for at least one major depressive episode
• Meets criteria for at least one hypomanic episode
• Does not meet criteria for manic or mixed episode
• Symptoms cause social/occupational distress or imairment

Bipolar NOS

• Disorder with bipolar features that do not meet criteria for specific bipolar disorder

Management

• Medically clear
• Place patient on legal hold if meets local criteria
• Arrange psychiatry evaluation (inpatient vs outpatient depending on clinical severity)

General ED Psychiatric Management

• Non-pharmacologic
  • Verbal de-escalation
  • Offer comforting items: blanket, meal, pillow, etc
  • Quiet room
  • Physical restraints (should administer medications if restraints used, as decreases restraint time)
• Pharmacologic: Goal is to calm patient without oversedation
  • No history of psychosis
    • Haloperidol 0.5mg-5mg +/- lorazepam 0.25-2mg (PO/IM/IV)
      • Consider adding benztropine 0.5-2mg or diphenhydramine 25-50mg (PO/IV/IM) (reduces dystonia or extrapyramidal reaction)
    • Consider risperidone 0.5-2mg PO or olanzapine 2.5-20mg (PO/IM/SL) or ziprasidone 10-20mg IM
  • Known or suspected underlying psychotic illness
    • Continue treatment with previous antipsychotic or
    • PO: olanzapine 5-10mg or risperidone 0.5-2mg +/- lorazepam: 0.5-2mg
    • IM: olanzapine 2.5-20mg or ziprasidone 10-20mg or
    • (PO/IM/IV) Haloperidol 0.5-5mg +/- lorazepam 0.5-2mg
      • Consider adding benztropine 0.5-2mg or diphenhydramine 25-50mg (PO/IV/IM) (reduces dystonia or extrapyramidal reaction)

Disposition

• May need psych eval after medical clearance

See Also

• General psychiatric workup

References

Authors

Ann Huang, Michael Holtz, Neil Young, Matin Shah, Daniel Ostermayer