Mood Disorders (Bipolar, Depression):

Definition/Etiology:

Bipolar is characterized by unpredictable phases of euphoria (or mania), and depression. These can occur for varied amounts of time and there can be long periods of no episodes between them.

Pathophysiology:

While Bipolar does have a hereditary component, it is believed to be caused by a combination of genes, the environment and psychological stressors. No we are not going to have a nature vs nurture conversation here but know that it is caused by a multitude of factors.

Clinical Presentation:

The presentation of BiPolar has 2 components. For the depressive phase, pts will present with:

• Feelings of worthlessness, loneliness, sadness, helplessness
• Loss of interest in previously enjoyed activities
• Guilt
• Fatigue
• Sleep disturbances
• Decreased libido
• Irritability
• Decreased ability to concentrate
• Suicidal ideation and a preoccupation with death

The presentation of mania is quite the opposite:

• Elation
• Mental excitement
• Irritability
• Pressured speech – this is rapid and kind of difficult to interrupt
• Flight of ideas – all over the place
• Increased motor activity, restlessness
• Grandiosity
• Impulsivity
• High risk behaviors
• Sexual acting out or preoccupation with sex
• Delusional thinking

Collaborative Management:

With all patients presenting with a mood disorder, we would want to get some blood work. Basic labs as well as toxicology to rule out an external factor or a medical disease process.

Depression:

• Safety and security
• Suicide risk
• Do not isolate
• Decrease environmental stimuli
• Encourage talking and expression of feelings
• Find out about support systems
• Be empathetic and non-judgemental
• Refer for psych and medical eval

Mania:

• Provide for safety
• Decrease environmental stimuli – i realize this may be difficult in the ED but it’s much better to put these patients in a room with the lights off then in the middle of the hallway
• Be authoritative but non-threatening – set limits
• Provide a safe room and allow for pacing
• Do not encourage patient to talk, be direct with questions
• Medicate as indicated
• Restraints as a last resort. This will come into play if violence becomes a factor

Evaluation | Patient Monitoring | Education:

Evaluating these patients is simply a factor of observing as their symptoms diminish. While in the ED you may only see a slight return to baseline. Depending on if they get medicated will most likely speed this process up but there is always the possibility that during their time with you there may be no change. It’s never a bad thing here, especially if there is history, to consult psych. Be aware of possible admission to a psych unit and if they are involuntary (danger to self or others), they might not take that well. When delivering news like that, always maintain your safety above all else.

Linchpins: (Key Points)

• Rule out medical
• SAFETY
• Quiet Environment
• Proper follow-up