Part 1 of this article (Psychiatric Times, July 2007, page 14), discussed a general approach to treating psychiatric emergencies in patients with bipolar and related disorders, as well as the assessment and management of agitation and impulsive aggression. Part 2 focuses on psychosis, suicidality, and specific treatments relevant to patients in emergency settings who are agitated or have bipolar disorder.Psychosis Clinical presentation
Psychosis is diagnostically nonspecific. In a patient who is prone to psychosis, any condition that can produce severe agitation can also induce psychosis. Psychosis can be caused by bipolar disorder itself, complications or treatment of bipolar disorder, or other medical or toxic conditions. Table 1 lists some medical and psychiatric conditions that may be associated with psychosis.Understanding the episode
A psychotic episode has 3 basic aspects: characteristics of the illness producing it, characteristics of the patient who is having the episode, and characteristics of the conditions associated with the specific episode.1 Clinicians must understand these characteristics so that effective initial and follow-up treatment can take place.
The illness. Psychotic episodes may occur as part of the natural history of an illness that produces susceptibility to psychosis, as part of an acute illness, or as part of an acute illness that is superimposed on a chronic illness that produces susceptibility to psychosis. In treating patients with bipolar disorder, it is especially important to be aware of this third possibility. Patients with bi-polar disorder are at risk for psychotic exacerbations because of drug intoxication or withdrawal, metabolic or neurological effects of medications, or endocrine disturbances that may be more common in bipolar disorder.2
Psychotic episodes in bipolar disorder, whether depressive or manic, have prodromes that may resemble those of any severe manic or depressive episode.3 Symptoms include changes in goal-directed activity, sleep, interpersonal behavior, or mood.4 In addition, characteristic prodromes of psychotic episodes include changes in sleep; activation; or sensory perception, including signs of overstimulation. For example, a patient may describe colors or sounds as being more vivid than usual, may be unable to ignore irrelevant environmental stimuli, or may begin to attribute meaning to random environmental events. Although these characteristics are general among psychotic episodes, in many psychiatric illnesses, the specific content and context, as noted in the next section, come from the life of the patient.
The individual. While the overall form of a psychotic episode may be similar for thousands of patients, the content of the delusions and hallucinations comes from the patient's life experience.1 Most patients with bipolar disorder have mood-congruent delusions and/or hallucinations; that is, the content is clearly related to the patient's affective state and usually to themes in his or her life that otherwise express themselves in a more mundane manner. However, a substantial minority of patients with bipolar disorder has psychoses with mood-incongruent delusions and/or hallucinations. These patients tend to have a more severe course of illness with more psychosocial impairment.5
The episode. Psychotic episodes result from the interaction between the patient's illness and its context. Psychotic episodes, in terms of global symptoms and time course, may be quite similar across many patients. Similarly, the generic circumstances associated with the likelihood of a psychotic episode may be similar across a large population, such as first manic or depressive episodes occurring during adolescence or childhood, postpartum epi- sodes, overstimulation, or affective episodes combined with substance use. Specific circumstances that have a high risk of recurrence of illness or psychotic episode are also based on the patient's specific experiences. For example, they may be associated with a recurring stressor or conflict in the patient's life or circumstances related to an earlier traumatic event.6Management
The initial pharmacological and nonpharmacological management of psychosis is essentially analogous to that of severe agitation (discussed below). Subsequent treatment is more dependent on the diagnosis. Differential diagnosis is also important because of the need to treat medical conditions that can be associated with psychosis.Suicidality Suicide risk factors
As many as 10% to 15% of patients with bipolar disorder may eventually commit suicide, and at least 25% of completed suicides in the United States are by patients with bipolar disorder.7 Table 2 summarizes clinical characteristics that are associated with risk of suicide. These characteristics identify people in whom the lifetime risk of suicide may be increased but do not define a person's risk of suicide at any specific time.
Lifetime risk increases progressively as patients exhibit more of the characteristics listed in Table 2. As discussed next, suicide risk at a given time is a result of the interaction between these lifetime risks and the acute context.The structure of suicidal acts
The prediction of specific suicidal acts is usually based on models that combine the patient's wish to die with the opportunity or inclination to carry out the act.8 In practical terms, suicidal behavior can be a result of a combination of depression and impulsivity. Hopelessness is the aspect of depression that is most severely associated with suicide.9
The combination of impulsivity and hopelessness is dangerous.10 Suicide attempts can vary from being predominantly premeditated, with prominent depression and feelings of hopelessness, to predominantly impulsive, with much less prominent depression but with the possibility of feeling hopeless without severe depression.11
In a person who is experiencing severe hopelessness and depression, any circumstance that increases impulsivity even slightly can markedly increase the risk of suicide, potentially leading to a suicidal act that may have been planned for months or years. Therefore, acute environmental stress, overstimulation, drug- or medicine-induced activation, sleep deprivation, or any other source of agitation can be associated with an increased risk of severe suicidal behavior.12
Conversely, in a highly impulsive person, a small increase in hopelessness can markedly increase the likelihood of self-destructive and suicidal behaviors. This is exacerbated by the fact that impulsivity is associated with lack of orientation for the future and with a tendency to give up when faced with adverse or complex situations.13 Thus, the impulsive person is predisposed to hopelessness in the relative absence of depression. Therefore, in predominantly impulsive suicide attempts, the severity of the method or injury may appear to have little to do with precipitating events. For example, a severely impulsive person may shoot himself as a result of a minor romantic setback or social slight.14
Substance abuse has both direct and indirect effects on suicide risk. Patients with comorbid substance abuse and bipolar disorder are at higher risk for suicide or suicidal behavior than are patients with either disorder alone. In addition, substance abuse is associated with higher risk of being a victim of violence,15 which, in turn, is associated with higher risk of suicide or suicidal behavior.16
Mixed states in bipolar disorder require special vigilance from clinicians.17 Mixed mania combines the impulsivity and activation of mania with depression and hopelessness that may be obscured by the more prominent manic behavior. Mixed depressions combine hopelessness and depression with the impulsivity of hypomania. Mixed states have more severe autonomic arousal than is the case in mania or depression alone.18 Affective states can shift within an episode19: mixed mania can arise out of mania and mixed depression can arise out of depression, with increased risk of suicide in both cases. In a shorter time frame, mood lability can increase the risk of suicide for similar reasons.
The danger of suicide is increased early in recovery from depressive or manic episodes20 or after recent discharge from hospitals or emergency departments (EDs).21 Functional recovery from an episode of illness takes longer than syndromal recovery.22 After being discharged from the hospital or having a reduction in intensity of treatment, patients face increased environmental stressors and stimulation at a time when apparent symptomatic improvement can lead to complacency. Depression or mixed states can follow manic episodes, and periods of activation or lability can occur late in depressive episodes, perhaps even more so if patients are being treated with antidepressants.20,23Approach to the suicidal patient
Physicians should assume that any patient seen in an emergency setting has the potential for suicidal behavior.24 Suicidality is also prevalent in nonpsychiatric patients presenting in the ED.15 With the exception of patients who have been rescued from suicide or have been brought in against their will, patients who are suicidal and present in the ED generally have some ambivalence about the act.
The physician must create a situation in which it is possible to elicit a history of the factors that contribute to suicide risk. It is generally reassuring to the patient who is suicidal and fearful to be asked questions directly, with competence and empathy, about his worst fears. It is unlikely that a patient has ever gotten the idea of suicide from being asked about it by a physician. It is equally important to understand the source of the patient's ambivalence—in other words, what it is that is keeping the patient alive.
General principles in interviewing a suicidal patient include24:
- Creating an environment in which the patient can talk about his worst fears: a setting with privacy, safety, reduced environmental noise, and an arrangement with the patient and physician seated on equal levels.
- Showing, in as many ways as possible, that the patient's situation is not as hopeless as he sees it, but that depression or other circumstances are temporary and treatable. Rather than lecturing or arguing with the patient, show this to him in every way possible. For example, when asking about the patient's loss of interest or pleasure, ask, "What do you usually like to do?" rather than "What did you like to do before you were depressed?"
- Asking the patient directly about feelings of hopelessness, wish to die, suicidal thoughts, and suicidal plans.
- If there are suicidal plans, determining how lethal the patient thinks they would be, as well as how lethal you think they are.
- Determining what steps the patient has taken toward carrying out the plan.
- If the patient has a plan and has obtained the means to carry out the plan but has not done so, determining why he has not and what circumstances would be required for him to see the plan through.
- Looking for verbal or nonverbal clues that show that the patient is no longer thinking about the future.
- Doing whatever possible to alleviate the patient's fear of loss of control. For example, if you think hospitalization is required, couch it in terms of allowing the patient to get control over his behavior and life, rather than as an attempt to control the patient.
- When assessing social supports and incorporating them into the patient's treatment strategy, remembering that even those who care deeply about the patient may become angry, ambivalent, or just need a rest from the situation.
- Taking pharmacological and nonpharmacological steps to reduce overstimulation, overactivation, and behavioral lability.
Acute treatments are those that can be used for relatively rapid treatment of severe or potentially severe behavioral disturbances. These treatments, in some cases, may also be useful in the longer term. Many treatments that are effective in patients with bipolar disorder have a more gradual onset of action, rendering them less useful for acute treatment. Under certain circumstances, however, treatment with these agents may be started in the emergency setting if the patient is known to have a diagnosis that will require longer-term treatment, if acute behavioral effects are not expected to increase behavioral problems, and if it can be assured that the patient's treatment response will be monitored.Pharmacological treatment
Antipsychotics.Antipsychotic agents are among the most effective means of pharmacologically reducing overstimulation and are considered to be effective in treating aggression in a wide range of conditions usually associated with psychosis or mania.25 The usefulness of conventional antipsychotic agents is limited by extrapyramidal effects and akathisia. There is also a risk of hyperthermia or neuroleptic malignant syndrome, especially in patients who are restrained and struggling in poorly ventilated seclusion rooms.
These problems can also occur with second-generation antipsychotics. Treatment should be aimed at specific symptoms rather than used for "chemical restraint."26,27 Droperidol(Drug information on droperidol) has been reported to be effective for relatively rapid stabilization of acute agitation and psychosis.28
Atypical antipsychotics, including clozapine, risperidone(Drug information on risperidone), olanzapine(Drug information on olanzapine), quetiapine(Drug information on quetiapine), ziprasidone, and aripiprazole(Drug information on aripiprazole), have the potential for effectiveness comparable to that of conventional antipsychotics but have the advantage of reducing the incidence of movement disorders. It is important, however, to note that severe movement-related disorders, most notably akathisia, can occur with atypical antipsychotic agents, as can neuroleptic malignant syndrome.29-31 Atypical antipsychotics are a heterogeneous group of medications with adverse effects that vary widely. Table 3 summarizes some properties of atypicals that are relevant to emergency treatment, compared with haloperidol(Drug information on haloperidol). When choosing medicine, clinicians should consider the impact of its side-effect profile on the tolerability of the specific patient, especially if long-term treatment is anticipated.32