Contributors:

Andrew White MD – Outpatient Psychiatrist; Fellowship Trained in Addiction Psychiatry; Denver Health

Travis Barlock MD – Emergency Medicine Physician; Swedish Medical Center

Summary

In this episode of Mental Health Monthly, Dr. Travis Barlock hosts Dr. Andrew White to discuss the elements of mania that may be encountered in the emergency department. The discussion includes a helpful mnemonic to assess mania, work-up and treatment in the ED, underlying causes of mania, mental health holds, inpatient treatment, and the role of sleep in mania.

Educational Pearls

• Initial assessment of suspected mania can be done via DIGFAST:

  • Distractibility – Individual that is unable to carry a linear, goal-directed conversation

  • Impulsivity – Executive functioning is impaired and patients are unable to control their behaviors

  • Grandiosity – Elevated mood and sense of self to delusions of grandeur

  • Flight of ideas – Usually described as racing thoughts

  • Agitation – Increase in psychomotor activity; start several projects of which they have little previous knowledge

  • Sleep decrease – Typically, manic episodes start with insomnia and can devolve into multiday sleeplessness

  • Talkativeness – More talkative than usual with pressured speech and a tangential thought process

• Interviewing patients requires an understanding of mood-based mania vs. psychosis-based mania

  • An individual with mood-based mania will more likely be restless, whereas a patient with psychosis-based mania will be more relaxed from a psychomotor standpoint

• Treatment of manic patients in the ED includes the use of antipsychotics to manage acute symptomatology

  • Management can be informed and directed by the patient’s history i.e. known medications that have worked for the patient

• ED management of manic patients involves a work-up for a broad differential including agitated delirium, substance-induced mania, metabolic disorders, and autoimmune diseases.

• Some individuals experience manic episodes from marijuana and other illicit substances

• Antidepressants used in bipolar patients for suspected depression may induce mania

  • Important to avoid using antidepressants as first-line therapy

• Mental health holds can be beneficial in patients with grave disabilities from mania

  • Oftentimes, undertreatment of manic episodes leads to re-hospitalization

• Inpatient treatment:

  • Environment is important – ensure that patients get solo rooms if possible to minimize stimulation

  • Antipsychotics, including risperidone and olanzapine, with or without a benzodiazepine, are useful for short-term agitation

  • Long-term treatment involves coupled pharmacological treatments with non-pharmacological treatments

• Sleep

  • Fractured sleep is one of the earliest warning signs that someone has an imminent manic episode

  • Poor sleep can be an inciting factor for mania, which then turns into a cycle that further propagates a patient’s manic episode

Summarized and edited by Jorge Chalit, OMSII | Studio production by Jeffrey Olson, MS2