Treating bipolar mania in the outpatient setting: Risk vs reward

Manic episodes, by definition, are associated with significant social or occupational impairment.¹ Some manic patients are violent or engage in reckless behaviors that can harm themselves or others, such as speeding, disrupting traffic, or playing with fire. When these patients present to a psychiatrist’s outpatient practice, involuntary hospitalization might be justified.

However, some manic patients, in spite of their elevated, expansive, or irritable mood state, never behave dangerously and might not meet legal criteria for involuntary hospitalization, although these criteria differ from state to state. These patients might see a psychiatrist because manic symptoms such as irritability, talkativeness, and impulsivity are bother­some to their family members but pose no serious danger (Box). In this situation, the psychiatrist can strongly encourage the patient to seek voluntary hospitalization or attend a partial hospitalization program. If the patient declines, the psychiatrist is left with 2 choices: initiate treatment in the outpatient setting or refuse to treat the patient and refer to another provider.

Treating “non-dangerous” mania in the outpatient setting is fraught with challenges:
• the possibility that the patient’s condition will progress to dangerousness
• poor adherence to treatment because of the patient’s limited insight
• the large amount of time required from the psychiatrist and care team to adequately manage the manic episode (eg, time spent with fam­ily members, frequent patient visits, and managing communications from the patient).

There are no guidelines to assist the office-based practitioner in treating mania in the outpatient setting. When considering dosing and optimal medication combina­tions for treating mania, clinical trials may be of limited value because most of these studies only included hospitalized manic patients.

Because of this dearth of knowledge, we provide recommendations based on our review of the literature and from our expe­rience working with manic patients who refuse voluntary hospitalization and could not be hospitalized against their will. These recommendations are organized into 3 sec­tions: diagnostic approach, treatment strat­egy, and family involvement.

Diagnostic approach
Making a diagnosis of mania might seem straightforward for clinicians who work in inpatient settings; however, mania might not present with classic florid symptoms among outpatients. Patients might have a chief concern of irritability, dysphoria, anxiety, or “insomnia,” which may lead clinicians to focus initially on non-bipolar conditions.²

During the interview, it is important to assess for any current DSM-5 symptoms of a manic episode, while being careful not to accept a patient’s denial of symptoms. Patients with mania often have poor insight and are unaware of changes from their base­line state when manic.³ Alternatively, manic patients may want you to believe that they are well and could minimize or deny all symptoms. Therefore, it is important to pay attention to mental status examination find­ings, such as hyperverbal speech, elated affect, psychomotor agitation, a tangential thought process, or flight of ideas.

Countertransference feelings of diagnos­tic confusion or frustration after long patient monologues or multiple interruptions by the patient should be incorporated into the diagnostic assessment. Family members or friends often can provide objective obser­vations of behavioral changes necessary to secure the diagnosis.

Treatment strategy
Decision points. When treating manic out­patients, assess the need for hospitalization at each visit. Advantages of the inpatient setting include:
• the possibility of rapid medication adjustments
• continuous observation to ensure the patient’s safety
• keeping the patient temporarily removed from his community to prevent irrevers­ible social and economic harms.

However, a challenge with hospitaliza­tion is third-party payers’ influence on a patient’s length of stay, which may lead to rapid medication changes that may not be clinically ideal.

At each outpatient visit, explore with the patient and family emerging symptoms that could justify involuntary hospitaliza­tion. Document whether you recommended inpatient hospitalization, the patient’s response to the recommendation, that you are aware and have considered the risks associated with outpatient care, and that you have discussed these risks with the patient and family.

For patients well-known to the psychia­trist, a history of dangerous mania may lead him (her) to strongly recommend hos­pitalization, whereas a pre-existing thera­peutic alliance and no current or distant history of dangerous mania may lead the clinician to look for alternatives to inpatient care. Concomitant drug or alcohol use may increase the likelihood of mania becoming dangerous, making outpatient treatment ill-advised and riskier for everyone involved.

In exchange for agreeing to provide out­patient care for mania, it often is helpful to negotiate with the patient and family a threshold level of symptoms or behavior that will result in the patient agreeing to voluntary hospitalization (Table 1). Such an agreement can include stopping outpatient treatment if the patient does not improve significantly after 2 or 3 weeks or develops psychotic symptoms. The negotiation also can include partial hospitalization as an option, so long as the patient’s mania con­tinues to be non-dangerous.