A unique element in behavioral health care — that of assessing a patient’s abnormal mood states — may on occasion be a special concern in the primary care setting. Comfort with assessing mood states and making appropriate psycho-social and medical interventions can be important skills. This eWeekly discusses the issues of mania and hypomania, as they may present in the primary care setting.
Mania and hypomania are mood states characterized by: elevated or irritable mood and a combination of symptoms such as increased energy, decreased need for sleep, irritability, feelings of inflated importance, excessive talkativeness (pressured speech), racing thoughts, exaggerated but poorly judged activities, and increased ‘pleasurable’ high risk behaviors. Mania or hypomania may also co-exist with depressive features in patients with bipolar profiles, so assessment may be challenging, but the presence of manic or hypomanic symptoms is a diagnostic key point. Input from relatives or others may be quite helpful in diagnostic assessment and treatment planning, as patients’ insight into their mood elevation may be impaired.
Levels of Care: When a patient presents with suspected manic or mixed affective symptoms, an early step in the process should include an evaluation as to the level of care needed. Assessment of the patient’s mood state, behavioral profile, and functionality are central to the triage and diagnostic process. Management options will range from acute referral for psychiatric care or prioritized referral for outpatient mental health care, but may also include primary care intervention to stabilize the patient’s symptoms while more intensive specialty care is being arranged. Medical evaluation of potential contributing factors will typically also be warranted as discussed further below.
Mania: In full blown manic states, patients typically present as pressured, intense and are often disorganized or showing restricted, hyper-focused interests. They often engage in harmful activities (e.g., reckless driving, substance use, sexual promiscuity) and may present with grandiose or even frankly delusional thinking, sometimes with psychotic symptoms such as hallucinations. Evaluation for both aggressive behaviors and suicidal tendencies needs to be undertaken and, most typically, referral for emergency psychiatric evaluation is warranted for stabilization and intensive treatment.
Hypomania: More subtle but still prominent changes in mood and behaviors are found in hypomanic states and deviations from a patient’s baseline personality is the central consideration to assess. Changes in sleep profile, an atypical sense of urgency about psychosocial issues, generalized psychological activation (rapid speech, internal thinking), and an altered level of judgment and insight about life activities are significant areas to note. A history of recurrent elevated mood episodes, not related to clear environmental stressors, may be diagnostically relevant.
Acute Stress Reactions: Differentiating manic symptoms from acute stress reactions to major life changes can be challenging as individuals’ responses to a variety of stressors (interpersonal problems, job crises, health problems, trauma exposure, etc.). Symptoms may include disruption in sleep, elevation of anxiety, and depressive mood and thought content. A central differentiating feature would be the absence of elevated mood and a coherence of the patient’s response to the stress.
Medical Concerns: Factors that may cause manic symptoms include medications such as antidepressants, which can trigger mania, as can stimulants and steroids (prescribed or used for body building). Recreational drug abuse or withdrawal may also trigger mania or mimic the symptoms, so obtaining a drug history and drug screen is recommended. Medical exam is important as manic symptoms may be mimicked in hyperthyroidism. A physical exam and a TSH level are indicated. Other medical differentials would include seizures or a stroke.
Primary Care Interventions: Recognition of the symptoms of mania and hypomania and review of the patient’s psychosocial functioning are first steps in PCP efforts. With a provisional diagnosis, medical evaluation and planning for appropriate referral are next steps.
When emergency referral is not needed, yet outpatient intervention is not readily available, efforts to manage disabling symptoms should be considered, typically focusing on sleep issues and psychomotor agitation. Typically, use of a sedating antipsychotic agent, such as quetiapine (Seroquel), or risperidone (Risperdal) in low to moderate dose range (Seroquel 50-100mg HS; Risperdal 1-2mg HS) could be considered as an initial intervention, with titration as indicated by patient response. Longer term treatments such as either lithium carbonate or an anticonvulsant mood stabilizer could also be considered as viable first line alternatives, but do require more lab monitoring (blood levels and LFTs with carbamazepine. Finally, short term use of a benzodiazepine might be considered for sleep and agitation.