Bipolar disorder, formerly known as “manic-depressive disorder,” is a major mood disorder affecting nearly 4% of the US population. Bipolar is a chronic, life-long illness much like diabetes, COPD, and heart failure. Its name reflects the “polar opposite” emotions and behaviors of depression and mania that are experienced by the patient at various times.
According to the Centers for Disease Control (CDC), it is considered the most expensive behavioral health diagnosis in the country, probably due to inpatient hospitalization rates which are much higher for bipolar (39.1%) than for other behavioral health diagnoses (4.5%).
Most people learn to manage their disease symptoms through a combination of medication and regular medical/psychiatric follow-up. Most are never hospitalized for their illness, and live productively like anyone else. When we speak of the “bipolar patient,” we must differentiate between the patient who is stable, on medication, and followed in the community (chronic disease) from the patient who presents to the ED in a crisis (acute illness).
In addition, we must further understand that patients may have other acute illnesses which land them in the hospital which are unrelated to bipolar, yet contribute to destabilization of their mental health. Think of the diabetic patient who has an A1C in desired range, and is compliant with medication, yet who becomes hyperglycemic or even acidotic when faced with a serious infection!
Here are four important things to keep in mind about the bipolar patient population:
The primary goal should always be medication compliance and regular outpatient follow-up.
In the hospital, you need to advocate for the patient to have few, if any, interruptions in home medications, and ensure that the medication record is correctly reconciled on admission and at discharge. If the patient has a psychiatrist or primary physician that follows them in the community (and does not come to the hospital), he or she should be notified on admission and contact information kept prominently displayed for other team members to see in the medical record.
Blood levels are important!
Many of the medications bipolar patients use require strict monitoring for therapeutic levels. Illness often affects the uptake of various medications, and even on an unchanged regimen blood levels can be sub- or supra-therapeutic. If you have a hospitalized patient with bipolar, it is always right to ask the doctor about ordering serum drug levels (i.e. lithium, valproic acid, lamotrigine).
Focus on safety and stabilization.
When the primary reason for admission is primarily related to mental illness (i.e. acute exacerbation of mania or depression), medical and nursing care will focus on safety and stabilization first. For some patients, a hospitalization for mania (extremely elevated, unrestrained, or irritable mood—usually manifested in risky or dangerous behaviors), or for depression (often with suicidal ideation and behaviors), is the first indication of their disease. The manic patient might be irrational, violent, or delusional; the depressed patient could have traumatic injuries associated with attempted self-harm.
Obtaining a good history from family (and if possible, the patient), is critical for directing care and services. Most hospitals have strict policies regarding the suicidal patient, including IVC (involuntary commitment), psychological evaluations, safety sitters, and specialized room preparation to remove any hazards that could be used violently against self or others (cords, sharp instruments, etc.).
Stabilization may occur in the ED or in an inpatient unit; some people will require additional treatment at a psychiatric facility after they are medically cleared. Case managers and social workers should be consulted on admission to begin to facilitate this process, since placement can often take longer than expected.
Community resources are the key to good outcomes and reduced hospitalizations.
Every acutely hospitalized patient with a serious mental illness will need a team on the outside to help. Access to affordable medical and psychiatric care, job placement, housing, and family or community support lessen the chance that the patient will have a serious crisis requiring hospitalization. In addition, some patients self-medicate with alcohol or drugs; they may also require access to substance abuse treatment as well.
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