APA Practice Guidelines

1. Perform a diagnostic evaluation

cont. from

The evaluation for bipolar disorder requires careful and thorough attention to the clinical history. Patients with bipolar disorder most often exhibit symptoms of depression but may also exhibit substance use, impulsivity, irritability, agitation, insomnia, problems with relationships, or other concerns. Patients rarely volunteer information about manic or hypomanic episodes, so clinicians must probe about time periods with mood dysregulation, lability, or both that are accompanied by associated manic symptoms (e.g., decreased need for sleep, increased energy).

One way to improve efficiency and increase sensitivity in detecting bipolar disorder is to screen for it, particularly in patients with depression, irritability, or impulsivity. The Mood Disorder Questionnaire is a 13-item, self-report screening instrument for bipolar disorder that has been used successfully in psychiatric clinics and in the general population (unpublished 2001 study of R.M.A. Hirschfeld). The general principles and components of a complete psychiatric evaluation have been outlined in the APA Practice Guideline for Psychiatric Evaluation of Adults.

2. Evaluate the safety of the patient and others and determine a treatment setting

Suicide completion rates in patients with bipolar I disorder may be as high as 10%-15% (8-13); thus, a careful assessment of the patient's risk for suicide is critical. The overwhelming majority of suicide attempts are associated with depressive episodes or depressive features during mixed episodes. The elements of an evaluation for suicide risk are summarized in . All patients should be asked about suicidal ideation, intention to act on these ideas, and extent of plans or preparation for suicide. Collateral information from family members or others is critical in assessing suicide risk. Access to means of committing suicide (e.g., medications, firearms) and the lethality of these means should also be determined. Other clinical factors that may increase the risk of a patient acting on suicidal ideation should be assessed; these may include substance abuse or other psychiatric co-morbidity, such as psychosis. The nature of any prior suicide attempts, including their potential for lethality, should be considered.

The ability to predict suicide or violence risk from clinical data is somewhat limited. Consequently, patients who exhibit suicidal or violent ideas or intent require close monitoring. Whenever suicidal or violent ideas are expressed or suspected, careful documentation of the decision-making process is essential. Hospitalization is usually indicated for patients who are considered to pose a serious threat of harm to themselves or others. If patients refuse, they can be hospitalized involuntarily if their condition meets criteria of the local jurisdiction for involuntary admission. Severely ill patients who lack adequate social support outside of a hospital setting or demonstrate significantly impaired judgment should also be considered for admission to a hospital. Additionally, those patients who have psychiatric or general medical complications or who have not responded adequately to outpatient treatment may need to be hospitalized. The optimal treatment setting and the patient's ability to benefit from a different level of care should be reevaluated on an ongoing basis throughout the course of treatment.

During the manic phase of bipolar disorder, a calm and highly structured environment is optimal. Such stimuli as television, videos, music, and even animated conversations can heighten manic thought processes and activities. Patients and their families should be advised that during manic episodes, patients may engage in reckless behavior and that, at times, steps should be taken to limit access to cars, credit cards, bank accounts, and telephones or cellular phones.

3. Establish and maintain a therapeutic alliance

Bipolar disorder is a long-term illness that manifests in different ways in different patients and at different points during its course.

Table 1
Characteristics to Evaluate in an Assessment of Suicide Risk in Patients With Bipolar Disorder^a

Establishing and maintaining a supportive and therapeutic relationship is critical to the proper understanding and management of an individual patient. A crucial element of this alliance is the knowledge gained about the course of the patient's illness that allows new episodes to be identified as early as possible.

continue: Monitor Treatment Response

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Written 4/02. Reviewed: 03/2006