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Provide extensive psychoeducation to the family (Table 3). Discuss these teaching points and their implications at length during the first visit and reinforce them at subsequent visits. Advise spouses that the acute manic period is not the time to make major decisions about their marriage or to engage in couple’s therapy. These options are better explored after the patient recovers from the manic episode.
Encourage the family to engage in mania harm-reduction techniques to the extent that the patient will allow (Table 4). In particular, they should hold onto their loved one’s credit cards and checkbook, and discourage the patient from making any major financial decisions until the mania has resolved. Additionally, patients should be relieved of childcare responsibilities during this period. If there are any child welfare safety concerns, the clinician will need to report this to authorities as required by local laws.
Advise family members or roommates to call emergency services and request a crisis intervention team, or to take the patient to an emergency room if he (she) makes verbal threats to harm themselves or others, is violent, or demonstrates behaviors that indicate that he is no longer able to care for himself. The psychiatrist should assist with completing Family and Medical Leave Act paperwork for family members who will monitor the patient at home, a work-excuse letter for the patient so he does not lose his job, and short-term disability paperwork to ensure income for the patient during the manic period.
These interventions can be challenging for the entire family system because they place family members in a paternalistic role and reduce the patient’s autonomy within the family. This is problematic when these role changes occur between spouses or between a patient-parent and his (her) children. Such changes typically need to be reversed over time and may require the help of a family or couple’s therapist. To support the psychological health of the patient’s family, refer them to the National Alliance on Mental Illness for family support groups or to individual psychotherapists.
Outpatient management can be rewarding
For “non-dangerous” manic patients who cannot be hospitalized involuntarily and refuse full or partial hospitalization, a psychiatrist must choose between beginning treatment in the clinic and referring the patient to another provider. The latter option is consistent with the APA’s ethical guidelines,31 but must be done appropriately to avoid legal liability.32 This decision may disappoint a family desperate to see their loved one recover quickly and may leave them feeling betrayed by the mental health system. On the other hand, choosing to treat mania in the outpatient setting can be rewarding when resolution of mania restores the family’s homeostasis.
To achieve this outcome, the outpatient psychiatrist must engage the patient’s family to ensure that the patient adheres to the treatment plan and monitor for potentially dangerous behavior. The psychiatrist also must use his knowledge of mood symptoms, cognitive impairments, and the psychological experience of manic patients to create a safe and effective treatment strategy that the patient and family can implement.
Because of mania’s unpredictability and destructive potential, psychiatrists who agree to treat manic patients as outpatients should be familiar with their state’s statutes and case law that pertain to the refusal to accept a new patient, patient abandonment, involuntary hospitalization, confidentiality, and mandatory reporting. They also should seek clinical or legal consultation if they feel overwhelmed or uncertain about the safest and most legally sound approach.
Bottom Line
Treating mania in the outpatient setting is risky but can be accomplished in select patients with the help of the patient’s family and a strategy that integrates evidence-based pharmacotherapeutic and psychotherapeutic strategies. Because manic patients could display dangerous behavior, be familiar with your state’s laws regarding involuntary commitment, patient abandonment, and mandatory reporting.
Related Resources
• National Alliance on Mental Illness. www.NAMI.org.
• Depression and Bipolar Support Alliance. www.DBSAlliance.org.
Drug Brand Names
Aripiprazole • Abilify Mirtazapine • Remeron
Asenapine • Saphris Olanzapine • Zyprexa
Carbamazepine • Equetro, Tegretol Pregabalin • Lyrica
Chlorpromazine • Thorazine Quetiapine • Seroquel
Clonazepam • Klonopin Risperidone • Risperdal
Diphrenhydramine • Benadryl Trazodone • Desyrel
Eszopiclone • Lunesta Valproate • Divalproex
Gabapentin • Neurontin Zaleplon • Sonata
Lamotrigine • Lamictal Ziprasidone • Geodon
Lithium • Eskalith, Lithobid Zolpidem • Ambien
Lorazepam • Ativan