Bipolar disorder: Difference between revisions
(Added General ED Psychiatric Management template) |
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*Symptoms only need to persist for 4 days | *Symptoms only need to persist for 4 days | ||
===Major Depressive Episode=== | ===[[depression|Major Depressive Episode]]=== | ||
*'''<big>S</big>'''leep - increased or decreased | *'''<big>S</big>'''leep - increased or [[insomnia|decreased]] | ||
*'''<big>I</big>'''nterest - losing interest or pleasure in activities | *'''<big>I</big>'''nterest - losing interest or pleasure in activities | ||
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*'''<big>G</big>'''uilt - excessive guilt | *'''<big>G</big>'''uilt - excessive guilt | ||
*'''<big>E</big>'''nergy - feels of fatigue, low energy | *'''<big>E</big>'''nergy - feels of [[fatigue]], low energy | ||
*'''<big>C</big>'''oncentration - cognitive | *'''<big>C</big>'''oncentration - cognitive decline, indecisiveness | ||
*'''<big>A</big>'''ppetite - weight loss/gain | *'''<big>A</big>'''ppetite - weight loss/gain | ||
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*'''<big>P</big>'''sychomotor agitation or depression | *'''<big>P</big>'''sychomotor agitation or depression | ||
*'''<big>S</big>'''uicidal ideation | *[[suicide|'''<big>S</big>'''uicidal ideation]] | ||
''Must have 5 symptoms in a 2 week period including depressed mood and loss of interest''<ref name="DSM5"/> | ''Must have 5 symptoms in a 2 week period including depressed mood and loss of interest''<ref name="DSM5"/> | ||
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*Usually will not be diagnosed in the emergency department | *Usually will not be diagnosed in the emergency department | ||
*Needs evaluation by a psychiatrist | *Needs evaluation by a psychiatrist | ||
*Rule out alternative medical explanation for symptoms, as appropriate | |||
{{General ED Psychiatric Workup}} | |||
===Bipolar I=== | ===Bipolar I=== | ||
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*Meets criteria for at least one hypomanic episode | *Meets criteria for at least one hypomanic episode | ||
*Does not meet criteria for manic or mixed episode | *Does not meet criteria for manic or mixed episode | ||
*Symptoms cause social/occupational distress or | *Symptoms cause social/occupational distress or impairment | ||
===Bipolar NOS=== | ===Bipolar NOS=== | ||
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==Management== | ==Management== | ||
* | *After medical evaluation/"clearance": | ||
*Place patient on legal hold if meets local criteria | **Place patient on legal hold if meets local criteria | ||
*Arrange psychiatry evaluation (inpatient vs outpatient depending on clinical severity) | **Arrange psychiatry evaluation (inpatient vs outpatient depending on clinical severity) | ||
{{General ED Psychiatric Management}} | {{General ED Psychiatric Management}} | ||
Revision as of 16:23, 10 October 2019
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[1]
- 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[1]
- 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 decline, indecisiveness
- Appetite - weight loss/gain
- Psychomotor agitation or depression
Must have 5 symptoms in a 2 week period including depressed mood and loss of interest[1]
Mixed Episode[1]
- Fulfill features of both manic and major depressive episode
- Must last at least 1 week
Differential Diagnosis
General Psychiatric
- Organic causes
- Psychiatric causes
Evaluation
- Usually will not be diagnosed in the emergency department
- Needs evaluation by a psychiatrist
- Rule out alternative medical explanation for symptoms, as appropriate
General ED Psychiatric Workup
- Point-of-care glucose
- CBC
- Chem 7
- LFTs
- ECG (for toxicology evaluation)
- ASA level
- Tylenol level
- Urine toxicology screen/Blood toxicology screen
- EtOH
- Urine pregnancy/beta-hCG (if female of childbearing age)
- Consider:
- Ammonia (see Hepatic encephalopathy)
- TSH (hypo or hyperthyroidism may mimic mental illness)
- CXR (for Tb screen or rule-out delirium in older patient)
- UA (for rule-out delirium in older patients)
- Head CT (to rule-out ICH in patients with AMS)
- Lumbar puncture (to rule-out meningitis or encephalitis)
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 impairment
Bipolar NOS
- Disorder with bipolar features that do not meet criteria for specific bipolar disorder
Management
- After medical evaluation/"clearance":
- 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
- Haloperidol 0.5mg-5mg +/- lorazepam 0.25-2mg (PO/IM/IV)
- 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)
- No history of psychosis
Disposition
- May need psych eval after medical clearance