Diagnosis and education are the key tasks in the hospital care of the first-episode patient. An initial hospitalization for suspected depression or mania may come about through referral from primary care physicians, psychiatrists who have conducted an initial evaluation in the outpatient setting, or
the emergency room. From the clinician’s perspective, the probable or definite diagnosis of a mood disorder may be clear, or at least may lead the possibilities in differential diagnosis. The patient on the other hand, especially in mania and sometimes in depression, may not understand what is happening. The buildup of symptoms may go on for several months before a patient comes to clinical attention; especially in mania weeks or months of negotiation by the worried family or outpatient clinician may precede actually getting the patient into the hospital.

Apart from obvious presentations where depression is the chief complaint and patients readily give the diagnostic history, the illness may present in ways that only later, on evaluation, give rise to the diagnosis of depression. Some examples include expressions of suicidality, or a suicide attempt; unexplained medical signs and symptoms, including pain, weight loss, or somatic preoccupations; or a state of feeling emotionally overwhelmed, sometimes presented as a “normal” reaction to adverse life events, but accompanied by marked difficulty functioning in everyday life.

Unlike depression, “mania” is almost never the patient’s chief complaint, although insomnia or agitation may be. More often, a manic episode, even one leading to hospitalization, does not even present with subjective distress on the part of the patient apart from anger at feeling coerced into treatment. As in depression, the initial diagnosis is sometimes clear to the clinician, but examples of less obvious presentations in which diagnosis emerges over time include first episodes of paranoid psychosis, violent or aggressive behavior, rapidly escalating patterns of substance abuse, or physical complaints of insomnia and exhaustion. In addition, complaints of depression and suicidality with extreme agitation or anxiety may herald an unrecognized mixed state.

In taking the history, participation of family members or others who know the patient well is essential, balancing appropriate confidentiality against the imperative to build alliances with others who will be essential in providing key information and supporting aftercare. In the case of newly admitted depressed patients, history is typically influenced by their current mood state which may negatively color perceptions, as well as recall difficulties due to poor concentration. The patient may view his or her emotions as entirely appropriate to dismal experience, real or distorted. By the same token, getting a history from an acutely manic patient on first admission can be challenging to even a skilled psychiatrist because of unwillingness to cooperate, as well as distractibility, sheer energy, and behavioral dyscontrol.

Of specific interest in the history for newly diagnosed or suspected mood disorders is the past history of subsyndromal mood episodes or enduring personality styles that were below diagnostic thresholds, unrecognized episodes of dysthymia or hypomania, or even frank undiagnosed major depression or mania. Nonbipolar depression is a diagnosis of exclusion, that the currently depressed patient has never been manic or hypomanic. Up to 20% of depressed patients become manic when treated with unopposed antidepressants, and delays of up to 10 years before accurate diagnosis of bipolar disorder are not uncommon. A brief structured interview, even using a formal tool such as the Mood Disorder Questionnaire, can be helpful to be sure this base is covered in the assessment.¹ Family history of bipolarity may also place a depressed person at risk for conversion to mania and is therefore vital to obtain.

As in all psychiatric patients, a history and workup is undertaken for differential diagnosis from states due to general medical conditions, medicines, or substances of abuse. Comorbid psychiatric conditions that affect treatment are common, especially substance abuse, anxiety, and personality disorders.

Once the psychiatrist is convinced that a mood disorder is in fact the correct primary diagnosis the process of education, explaining what is happening, the rationale for medication, goals of psychotherapy in the hospital, and what time course to expect for improvement and recovery can begin. During the hospital stay, patients and families can be mobilized to gather extensive information regarding areas such as family history and prior undiagnosed mood episodes. The first mood episode is a crucial time to provide the realistic hope that recovery is expected, tempered by the reality that there may be a process of trial and error before an ideal regimen is found. Patients must be educated about how long to continue treatment to prevent relapse of the current episode or recurrence of future episodes.

The first hospitalization is the time to look at other aspects of the patient’s situation that will help the psychiatrist understand the context of the illness, tailor aftercare and near-term life decisions, and motivate the patient to follow through with what may become many years, if not a lifetime, of preventive treatment. Such factors include, of course, the common comorbidities such as substance use disorders, anxiety, and personality disorders, as well as interpersonal stresses broadly. Patients are encouraged to
think psychologically about themselves in ways that are not necessarily geared toward pathology but also take into account strengths, personality styles, and life goals as these interact with their mood disorders.

Understanding barriers to care is the key goal in the hospitalization of the patient with a severe, recurrent episode of a known diagnosis of bipolar disorder or depression but who is not under care at the time of admission. Why has this happened now and what can be done to prevent it from happening again? What is discovered will set the tone for the major psychological work of the hospital stay, above and beyond the issues in treating the episode itself. These barriers can be explored in a manner as systematic as the history taken in the first episode to establish the diagnosis of mania or depression.

First, several psychiatric issues must be considered. Inadequate prior treatment may have left residual symptoms that reduced motivation for ongoing care. There may be comorbid conditions interfering with treatment, such as a personality disorder or substance abuse. Side effects of medicines may have led to nonadherence.

Second, attitudes toward illness may have impeded care. Denial and lack of insight may be part of the disease process itself as well as parts of a psychological defensive structure. Classic components include enjoying positive aspects of mania or being hopelessly pessimistic in depression. Secondary gain of illness represents another unconscious dimension of care rejection. Fear of stigma in the social world of the patient or a negative and critical family attitude toward mental illness and the need for treatment may also discourage care.

Third, there may have been inadequate past psychoeducation, with a lack of knowledge about signs and symptoms of a new episode of mania or depression, and lack of information about the importance of continuation treatment in reducing future episodes. Lastly, there may be problems in the care delivery system available to the patient, either because of lack of financial resources or lack of access to knowledgeable providers with the proper expertise.

The treatment team evaluates the contribution of these factors to “dropping out” from care. The easiest part of care is recognizing the mood disorder, obtaining prior treatment history, and reinstituting appropriate medication. If medication side effects or an incomplete prior response are the culprits, alternative regimens should be used; if previous medicines worked but other factors led to nonadherence, the inpatient team will need to expend great effort addressing the root cause of the disconnect. Psychosocial work and psychoeducation will be paramount in reducing barriers to long-term well-being.

To this category belong patients who may be admitted either emergently or electively for mania, depression, or patterns of continuous cycling that have become resistant or refractory to treatment. True episodes of prolonged mania are rare but enormously consuming of hospital resources such as one-to-one security, use of seclusion and restraint, and effects on other patients on the inpatient unit. Most patients with treatment-refractory mood disorder suffer from chronic depression, both in bipolar illness and recurrent major depressive disorder. Patients may experience considerable demoralization and disability, increasing the risk of family stress, divorce, unemployment, and a further slide toward suicidality. Apart from the usual indications for inpatient care (safety, inability to function, intensity of suffering), the hospital care of these patients uses the full involvement of the round-the-clock staff to achieve interlocking goals revolving around four issues for systematic reevaluation: diagnosis, adequacy of previous medication, adverse effects of medication, and psychosocial management. In effect, the inpatient stay is in part an extended consultation.

First, diagnostic reevaluation can proceed at several levels. There may be episode features such as psychotic symptoms that have been overlooked requiring the use of antipsychotics or electroconvulsive therapy (ECT). Underlying diagnosis may be changed, such as reclassification from nonbipolar to bipolar disorder, agitated depression to mixed episode, or mood disorder to schizoaffective illness or schizophrenia. One may be able to identify a complicating comorbid psychiatric disorder diagnosis
whose symptoms overlap with the mood disorder, but which needs focused treatment in order for mood disorder treatment to succeed, for example, substance abuse, anxiety disorders, attention deficit hyperactivity disorder, or personality disorders. Finally, inpatient workup and treatment may be needed for a complex medical condition that overlaps with a mood disorder or complicates its treatment, such as many central nervous system disorders, autoimmune diseases, heart disease, or pregnancy.

Second, the psychiatrist should revaluate the adequacy and effects of prior medication treatment by a detailed, chronologic review: Were doses and durations of treatment appropriate? Were all suitable medicines actually tried? Was abandonment of a medicine because of a side effect truly warranted—were doses lowered, or antidotes tried? Physicians can make an enormous effort in the hospital to unearth this information by systematically obtaining prior treatment and pharmacy records, especially before an elective admission, and then treat through the gaps. They can also retry promising, but poorly tolerated, medicines at lower doses, or promising, but inadequately dosed, medicines at higher levels, both with close side effect and safety monitoring. In conducting this review, a structured psychopharmacology treatment interview²,³ and the visual technique of “life charting” are often helpful aids.⁴

Third, the present authors use the hospital to eliminate some or all medicines in the polypharmacy regimens that may accumulate in treatment-resistant patients, a step that can provoke great anxiety in patients and psychiatrists alike, for fear of worsening the situation. One reason to “clear the decks” is to rule out side effects that resemble psychiatric symptoms, such as extrapyramidal or cognitive side effects mimicking depression. Another common objective is eliminating antidepressants from the regimen of a patient with bipolar disorder who may be experiencing paradoxical worsening of depression or mood cycling.

Fourth, it is important to reevaluate the outpatient psychosocial management. Are there major life stressors that have gone unaddressed? Major losses (e.g., a spouse, a child or parent, a therapist, a home, a job) are associated with relapses into both mania and depression. As an example, in the 6 months after the death of a prominent psychiatrist in the authors’ area, several of his former patients were admitted to the authors’ unit. Almost none of them, on admission, identified his death as a stressor, yet all of them recognized its importance as the treatment proceeded. On occasion, the patient may be receiving the wrong type of psychotherapy, however well intentioned. Psychotherapy can intensify mood symptoms, such as marital or family therapy that inadvertently creates greater conflict. Tactfully exploring a meaningful but misguided therapeutic relationship may be a factor in understanding apparent treatment-resistant mood states. Instituting more constructive approaches and dealing with potentially explosive family conflicts may be needed while the patient is in the safe environment of the hospital. It is also common for patients to have not received specific, evidence-based approaches such as cognitive behavior therapy that are not widely available in community-based outpatient centers.

Finally, treatment-resistant cases may be seen where appropriate new treatment has been started recently before the patient enters the hospital but has not had sufficient time to bear fruit. All that may be needed is confirmation of the approach without undertaking an overhaul.

Acutely manic patients are, perhaps, the most difficult of all psychiatric patients to treat due to the complexity of both psychological and pharmacologic management. Full cooperation with treatment is rare. Mania is accompanied by impairments in judgment, insight, observing ego, impulse control, anxiety and frustration tolerance, and often in reality testing itself. Therefore, the clinicians may find themselves treating a patient who not only does not want their help, but also can be nasty, belligerent, irritating, and even litigious. Often admitted involuntarily, they may insist on a court review of their admission. Not uncommonly, medicines are refused and may not be given over objection if the patient is not imminently out of control of impulses. With treatment at a standstill, a court order may be needed.

When a manic patient arrives on the floor, these psychological and pharmacologic difficulties must be expected. In addition to a detailed history of his or her symptoms and a diagnostic formulation, the mental status examination must carefully focus on mood symptoms such as irritability, cognitive distortions (loose associations or flight of ideas or delusions), perceptual abnormalities (hallucinations), suicidal or homicidal thoughts, plans and actual current or past attempts, loss of impulse control, or deficits in insight or judgment. On admission, the alliance with such patients does not exist and will develop over time only as the psychopathology resolves. Unskilled clinicians and trainees often mistake compliance shortly after admission for a developing alliance. The experienced clinician recognizes that manipulation, as well as deception, are part of the manic patient’s presentation. When treatment has been given over objection, patients’ reactions are complex. When they recover, many agree that coercion was justified⁵ even if they remain ungrateful.⁶

Nursing assessment in conjunction with the physician’s evaluation is crucial at this juncture to facilitate patients’ integration into the milieu. Issues such as room assignment for ease in monitoring and a level of observation (e.g., frequent checks or close observation by an individual staff member) must be decided. Medication and dosing frequency as well as other aspects of the treatment plan should be clear to all staff members. This point cannot be stressed enough. Manic patients, often threatening and frightening to staff, may bully other patients on the unit, for example, determining which television shows will be watched or taking whatever food they may see and want. Early communication between team members is crucial to treating the current psychopathology without any individual believing that the patient would be better left alone (often a countertransference pitfall that hardly serves the patient).

Although inpatient psychiatrists may be busy off the unit for hours at a time with other duties, the nursing staff, floor attendants, and activities therapists are on the front lines, interacting with the patients more closely and continuously assessing their overall condition. A manic patient who is
about to lose control will more likely be identified by these staff members, who must be prepared at all times to defuse the situation. De-escalating interventions can include verbal reassurances, “time-outs” in the patient’s own or quiet room, and offers of p.r.n. medication. At times a “show of force” with the possibility of restraint or seclusion may be necessary. Formal programs exist to train nursing and security staff in managing the aggressive patient;⁷ the nature of the threat and the number of staff members available and formally trained in “take-down” techniques are factors in whether to call for security backup. These issues are discussed further in Chapter 12.

Social work involvement is essential from the moment the patient arrives on the unit. Relatives and/or significant others need to be contacted to clarify history and the emergence of symptoms, as well as to clarify comorbid conditions and family psychiatric history. Family members should be seen as close to admission as possible, allowing an alliance to develop. Healthier family members may help implement treatment later in the hospital course if the patient is nonadherent with those recommendations. In addition, enabling behaviors by relatives and friends which impede treatment can also be identified early. The limited available research on inpatient family therapy suggests that the focus should be psychoeducation and that benefits are more pronounced in female patients.⁸

For the newly presenting case as well as in the questionable diagnostic cases, it is sometimes difficult to distinguish hypomanic or mixed mood states (and on occasion even manic states) from severe character pathology with borderline features. Overlapping behaviors include irritability, controlled but aggressive behavior, flirtatiousness, seductiveness, sexually inappropriate behavior, manipulativeness, sarcastic devaluation of others, and oppositional behavior. Many of these interpersonal maneuvers have been described by others⁹ and make for challenges in treatment second to none.

The hospital played an indispensable role in her recovery. It allowed the team to stop her medication, a step that everyone had been afraid to take without a complete safety net; containment of behavior that was increasingly damaging to key relationships; confirmation of a serious underlying diagnosis of bipolar disorder; and initiation and continuation of a treatment that she otherwise would not have cooperated with, but for which she was subsequently grateful.

With this vignette in mind, one can see how challenging it is for staff to treat these patients when, at times, they are being verbally or physically abused by the patient. Educating new staff members about bipolar patients, reviewing the countertransferences generated toward bipolar patients, and discussing psychopathology with staff is very helpful in easing the strong feelings such patients engender in staff members. After the patient has improved and is ready for discharge, reviewing the resolution of symptoms and focusing on the most annoying and disruptive behaviors as well as on the feelings each staff member may have experienced as they cared for this patient has great educational and clinical value.

The pharmacotherapeutic approach to mania is to try and “get it right” the first time by combining medicines in aggressive doses in order to maximize the odds of rapidly stabilizing mood, thinking, and behavior. The American Psychiatric Association (APA) practice guideline for bipolar disorder¹⁰ recommends the combination of lithium or divalproex, or potentially carbamazepine, with an antipsychotic, preferably an atypical. Any antidepressants the patient had been taking should be stopped, on the assumption that they may be causing the episode.