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Patient behaving strangely

Case

history

Mrs Smith has called you to see her husband who has been behaving strangely over the last few days, refusing to go to bed and talking to her incessantly about his plans to leave his job, trek across South America and stand as an MP. She is clearly worn out, whereas Mr Smith is full of energy, busy 'tidying out' the kitchen which is in chaos. He informs you he is about to drive to the garden centre so he can completely restock the garden. Dr Melanie Wynne-Jones discusses.

How should you react?

With a visit request like this you should telephone to get as much information as you can before visiting.

This enables you to do a risk assessment for all concerned – including yourself – and decide whether you need to speak to or involve anyone else, such as the duty psychiatrist, Mr Smith's key worker if he is already known to the mental health services, or even the police.

A calm, polite approach is most likely to succeed; grabbing his arm or arguing with Mr Smith may agitate him further. He is probably unsafe to drive. You may be able to persuade him to talk to you so you can do a proper mental state examination, but he may refuse to engage.

Either way you are likely to need the psychiatrist's opinion.

Does Mr Smith need hospital admission?

Probably, as the cause and severity of his unusual behaviour need to be established, and he may be a risk to himself and/or others. Most likely diagnosis is hypomania, but substance abuse, physical illness and other causes of psychosis must be excluded.

If he is already on medication the dose may need to be reviewed; occasionally psychosis may be due to an adverse reaction to other drugs such as

malarone.

If he retains some insight and trust he may agree to go in voluntarily. If not, he will need compulsory admission for assessment under section 2 of the Mental Health Act (1983)1.

Three signatures are required – yours, as someone who has previous acquaintance with Mr Smith, the psychiatrist's (or another doctor approved under section 12 of the Act) and an approved social worker. It may be some time before they can attend and a bed can be found; an ambulance, and possibly the police, will be needed.

In extreme emergency, Mr Smith could be admitted under section 4 for up to 72 hours on the basis of your signature alone, but this is rarely used as it is not usually justifiable.

What treatment will Mr Smith need?

Section 2 covers admission for assessment for up to 28 days; after that it would have to be converted to a section 3 application to treat Mr Smith for up to six months (renewable).

Treatment for hypomania depends on whether the patient is already receiving treatment for bipolar disorder, the severity of psychotic symptoms and the patient's own views2.

An (atypical) antipsychotic or valproate will help to stabilise Mr Smith's mood; he may need a benzodiazepine to sleep. Lithium, and occasionally clozapine or even ECT, are needed in severe or refractory cases.

Once he is well enough, the question of long-term treatment and prevention of recurrences should be considered. Continuous and indefinite treatment with mood stabilisers such as lithium, valproate or carbamazepine may be needed, with short-term add-ons such as benzodiazepines or olanzipine. Lower doses are used in the elderly; pregnancy and breast-feeding may restrict options.

What is the long-term outlook for Mr Smith, assuming he has hypomania?

Mr Smith has had an episode of hypomania, he has bipolar I disorder, a condition that affects 0.5 per cent of the population. He has never had major depression (which would convert the diagnosis to bipolar II, a more common condition) but may yet do so.

He may suffer further episodes of hypomania or depression, and his lifetime risk of suicide is increased. Alcohol and substance misuse are risk factors for bipolar disorder and need assessment.

He will need regular supervision and support; he need monitoring with blood levels and may be keen to discontinue treatment that has unpleasant side-effects. Psychological therapies such as cognitive or family therapy or attending a support group may raise compliance and reduce the chances of a relapse.

Implications under the new contract3?

The name of Mr Smith's key worker and main carer (Mrs Smith) should be recorded in his records.

To maximise points in the mental health domain of the quality and outcome framework:

lMr Smith's name should be added to the severe mental illness register – appropriate Read code (9H8..).

lHis mental health and medication should be reviewed at regular intervals and recorded as 6A6 and 8B3S respectively.

lHis lifestyle and physical health should be reviewed regularly and appropriate advice recorded.

lHe should have his serum lithium levels recorded (normal therapeutic range 0.6-1mmol/l) every six months, and his renal and thyroid function checked annually. The Read codes for lithium levels, serum creatinine and thyroid function tests are 44W8, 44J3 and 442A respectively.

lThe practice should audit Mr Smith's care regularly to check it is satisfactory, and that points are not being lost.

Melanie Wynne-Jones is a GP in Marple, Cheshire

Key points

lBefore visiting in acute psychiatric emergency, assess the situation and risk by telephone first wherever possible.

lEmergency admission to hospital under section 2 of the Mental Health Act normally involves the GP, a section 12 approved doctor and an approved social worker.

lHypomania carries a high risk of recurrence and suicide.

lLithium should be prescribed by brand and monitored carefully.

lPatients with severe mental illness are included in the new contract's quality and outcome framework. They should be included on the severe mental illness register and their records should contain the correct Read codes to enable their care to be audited.

Lithium treatment

Branded prescribing is recommended because of variations in bioavailability4

Side-effects

lFine tremor

lThirst and polyuria

lWeight gain and oedema

lRashes

lGastrointestinal disturbances

lRaised white count

lHypothyroidism

Overdosage

lCoarse tremor

lNausea and vomiting

lAtaxia, twitching, dysarthria, poor

co-ordination, hyper-reflexia

lFits, coma

lRenal failure

References

1. Royal College of Psychiatrists Webguide –

The Mental Health Act www.rcpsych.ac.uk/info/webguide/mha.htm

2. Evidence-based guidelines for treating bipolar disorder: recommendations from the British Association for Psychopharmacology (2003)

www.bap.org.uk/consensus/

FinalBipolarGuidelines.pdf

3. The New GP Contract (2003) BMA Blue Book

4. British National Formulary

Self-help and support

•Manic Depression Fellowship, Castle Works, 21 St George's Road, London SE1 6ES Tel: 020 7793 2600 A user-led organisation providing support nationwide

www.mdf.org.uk

•Royal College of Psychiatrists – leaflets and factsheets on manic depression/ bipolar disorders, 17 Belgrave Square London SW1X 8PG Tel: 020 7235 2351

www.rcpsych.ac.uk/info/bipdis.htm

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