APA Practice Guidelines

III. Special Clinical Features Influencing the Bipolar Treatment Plan

A. Psychiatric Features

1. Psychosis

Psychotic symptoms (e.g., delusions, hallucinations) are commonly seen during episodes of either mania or depression but are more common in the former, appearing in over one-half of manic episodes. Mood-congruent features during a manic episode probably are not predictive of a poorer outcome, although early onset (before age 21) of psychotic mania may predict a more severe disorder. Mood-incongruent features have been identified in some but not all studies to be a predictor of a shorter time in remission. The presence of psychotic features during a manic episode may not require an antipsychotic medication, although most clinicians prescribe them in addition to a maintenance agent.

2. Catatonia

Catatonic features may develop in up to one-third of patients during a manic episode. The most commonly observed symptoms of catatonia in mania are motor excitement, mutism, and stereotypic movements. Because catatonic symptoms are seen in other psychiatric and neurological disorders, a careful assessment is indicated for an accurate diagnosis. In addition, patients who exhibit catatonic stupor may go on to show more typical signs and symptoms of mania during the same episode of illness. The presence of catatonic features during the course of a manic episode is associated with greater episode severity, mixed states, and somewhat poorer short-term outcomes. In treating catatonia, neuroleptics have generally exhibited poor efficacy. In contrast, prospective studies have demonstrated the efficacy of lorazepam in the treatment of catatonic syndromes, including those associated with mania. Since ECT is probably the most effective treatment for catatonic syndromes regardless of etiology, ECT should be considered if benzodiazepines do not result in symptom resolution.

3. Risk of suicide, homicide, and violence

Like those suffering from major depression, patients with bipolar disorder are at high risk for suicide. The frequency of suicide attempts appears similar for the bipolar I and bipolar II subtypes. Individuals with bipolar disorder repeatedly have been shown to have greater overall mortality than the general population. Although much of this risk reflects the higher rate of suicide, cardiovascular and pulmonary mortality among patients with untreated bipolar disorder is also high.

Known general risk factors for suicide also apply to patients with bipolar disorder. These include a history of suicide attempts, suicidal ideation, co-morbid substance abuse, co-morbid personality disorders, agitation, pervasive insomnia, impulsiveness, and family history of suicide. Among the phases of bipolar disorder, depression is associated with the highest suicide risk, followed by mixed states and presence of psychotic symptoms, with episodes of mania being least associated with suicide. Suicidal ideation during mixed states has been correlated with the severity of depressive symptoms. In general, a detailed evaluation of the individual patient is necessary to assess suicidal risk. Judgment of suicidal risk is inherently imperfect; therefore, risks and benefits of intervention should be carefully weighed and documented.

Long-term treatment with lithium has been associated with reduction of suicide risk. Whether this reflects an anti-impulsivity factor beyond lithium's mood-stabilizing effect is not yet clear. Lithium may also diminish the greater mortality risk observed among bipolar disorder patients from causes other than suicide. It is unknown whether prolonged survival is also seen with the anticonvulsant maintenance agents.

Clinical experience attests to the presence of violent behavior in some patients with bipolar disorder, and violence may be an indication for hospitalization. Co-morbid substance abuse and psychosis may contribute to the threat of criminal violence or aggression.

continue: Substance Use Disorders

top . pages 1 2 3 4 5 6 . send to friend . bipolar site map

Written 4/02. Reviewed: 03/2006