Dr Rory Shelley, Consultant Psychiatrist and Clinical Lecturer at St John of God Hospital and TCD, examines the management of hypomania and mania in primary care
GPs are positioned to play a crucial role in the management of mania and its less severe form, hypomania. In this regard, there are two aspects of an elevated mood worth considering:
1) The early identification of an evolving mania;
2) Detecting episodes of hypomania that might be overlooked.
Within the context of a mood disorder, an elevated mood may present as hypomania or mania. This distinction has been used to sub-classify bipolar mood disorder into bipolar I (BPI) and bipolar II (BPII). Bipolar II is characterised by episodes of depression associated with periods of hypomania, but never mania. Bipolar I is characterised by depression and at least one episode of mania.
Epidemiology
The lifetime prevalence of both BPI and BPII has been estimated to be as high as 5 per cent. The overall male to female ratio is 1:1, but more females may present with bipolar II. The onset is usually in the early twenties and is thought to be the same for both BPI and BPII, although males tend to present at an earlier age.
The classic features of a manic episode are generally readily recognised. These include an elated mood, pressure of speech, physical over activity and grandiosity, which may become delusional. In this case, the therapeutic interventions are likely to include admission to an acute psychiatric unit.
Much successful effort has been invested in the prompt detection and treatment of depression. It is therefore perhaps timely to consider focusing on the early detection of its mirror image, mania and hypomania.
Mania: (BPI)
An acute episode may escalate over one to two weeks. In the earliest stages, the person may subjectively have a sense of wellbeing and an increase in energy. They may feel interested in new challenges and gain confidence in their ability to handle difficulties.
As an episode becomes more acute, the level of activity becomes clearly over active. The person becomes potentially more irritable and friction emerges in their interactions with family and work colleagues. Although sleep is much reduced, they do not feel tired. Their capacity to make judgments becomes impaired and they become notably distractible.
At this stage, concern will be evoked by family and friends that something is not quite right, perhaps then bringing the person into a primary care setting. Interviewing the patient may fail to identify any overt features of an elevated mood. In such situations the individual may be well capable of containing themselves for limited periods of time. Therefore, collateral information from a relative, who often looks exhausted, is crucial.
Where a patient presents with these symptoms and has a previous episode of treatment for depression, the possibility of bipolar affective disorder should be considered.
A patient with bipolar disorder can be typically said to have had ‘unstable lives, failed careers, divorces and turbulent biographies’. Failure to treat may result in significant impact on a person’s quality of life, specifically in terms of relationships and careers.
Secondary mania
When meeting such a patient for the first time, it is important to consider, especially in older patients, that the mood change may be secondary to other aetiological factors including:
1. CNS disorders: cortical or sub-cortical lesion, HIV or multiple sclerosis;
2. Illegal substance misuse;
3. Iatrogenic: corticosteroids and antidepressant medication.
Managing acute mania:
Where possible, in the early stages, it is important to try and establish a working relationship with the patient. Communicate clearly and honestly what you are thinking. Conducting medical investigations to rule out a secondary mania may elicit the patient’s cooperation. Seek telephone advice from local psychiatric services, including about initiating treatment, e.g. with a mood stabiliser such as valporate (Epilim) or an atypical antipsychotic.
As the mood further elevates, irritability, lack of insight and poor judgment make management more challenging. An acute case is an emergency. Admission becomes indicated. This might require an admission order under the Mental Health Act (2001), especially where risk emerges. Risk assessment includes risk to self and others in areas such as family, work, driving, sexual behaviours and misuse of alcohol or illegal substances.
The admission process may be facilitated by the co-administration of an atypical antipsychotic with a benzodiazepine.
Hypomania: (BPII)
Patients who have a history of depressive episodes may have their periods of hypomania overlooked. More than half of patients with bipolar mood disorder have had their episodes of hypomania missed, resulting in misdiagnosis as having only a depressive disorder. As a consequence, the unwise use of antidepressant medication and the absence of mood stabilisers put these patients at risk for switching to acute manic episodes and also increase their rate of cycling mood.
Other incorrect diagnoses include anxiety disorder, personality disorders such as borderline or antisocial, ADHD, or schizophrenia. Patients may contribute to this by one out of three not reporting all of the behaviours associated with their elevated mood.
Clues of hypomania:
The primary care setting is one in which GPs may be well placed to pick up clues indicative of hypomania, such as the following which are out of character for the individual:
l Episodes of increased energy and enthusiasm;
l Risk taking or seeking extra stimulation;
l Insomnia without fatigue;
l Interactions characterised by disinhibition or insensitivity;
l Enhanced sensory experiences, e.g. more vivid colours;
l Spending money inappropriately;
l Bouts of creativity;
l Irritability if plans are thwarted.
Screening for hypomania (BPII)
A number of screening tests have been devised to assist in the recognition of a BPII mood disorder. A good example is ‘The Mood Disorder Questionnaire’ (R Hirschfield et al, Am J Psychiatry, 2000, 157: 1873-1875). This screening tool has good sensitivity (0.73) and very good specificity (0.90) in an outpatient setting.
A simple single question to screen for a hypomanic mood is: ‘Have you ever in your life experienced an episode lasting three or more days when you needed much less sleep than normal, yet had more energy and activities than usual, felt ‘wound up’ or ‘on top of the world’ and had racing thoughts?’ (C Lake & J Baumer, Current Opinion in Psychiatry, 2010, 33: 157 – 166.)
Impact on carers:
To be involved in the care of a family member with elevated mood is associated with increased levels of stress and distress. The impact can be understood using a cognitive model. According to this model, the carer can be helped by recognising that the patient is not to blame for their illness, and in turn the carer needs to adopt a more parental-like role in order to provide appropriate care.
Carers might require permission to look after themselves as well as being given information as to how to access further information, such as through the AWARE organisation. Where indicated, the application of a CBT model therapeutically has been shown to be helpful and the outcome includes the carer being able to recognise the positive aspects of their role.
Longer term management:
As well as contributing significantly to the early identification of bipolar disorder, GPs are well placed to be involved in ongoing shared care with psychiatric services. This includes providing general medical care, especially being mindful of the longer term consequences of mood stabilisers and atypical antipsychotics.
It is recognised that lithium prophylaxis can lead to under-activity of thyroid function and decreased renal function. Valporate may be associated with abnormality in liver function and reduced platelet count. Atypical antipsychotics also require monitoring of fasting blood sugar and lipids.
GPs are also aware of the family and social circumstances affecting their patients and they can be of significant support to carers who are experiencing a ‘burden’ of care.
Patients with BPI and BPII should be encouraged to maintain a regular rhythm to their daily routines, including maintaining a regular sleep/wake cycle. Patients on long-term prophylaxis and receiving repeat prescriptions can have their compliance enhanced in the GP surgery.
Monitoring and dealing promptly with side effects can be particularly useful in this regard. It is furthermore very useful for early warning signs to be identified and written down, with agreed action (e.g. contact GP or psychiatric services) should any emerge.
Conclusion
The primary care setting is where the early recognition of a manic episode may allow an effective intervention without an acute emergency evolving. Similarly unrecognised hypomania and BPII can be diagnosed, thereby avoiding misdiagnosis and inappropriate treatment.
l Dr Rory Shelley,
Consultant Psychiatrist and Clinical Lecturer, TCD,
St John of God Hospital,
Stillorgan, Co Dublin.
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