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MrMouse

Mania - informal inpatient ?issues

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Current inpatient with hypomania but retains very good insight which I know is unusual.  She rang the hospital herself to request admission knowing that she was starting to become elated.  Now sexually disinhibited on the ward. Currently on one-to-one observations because of sexual disinhibition which is marked and makes her vulnerable.  What are people's views about an informal patient being on one-to-one observations.  She consents to this, has capacity to understand this. Also she made a few inappropriate phone calls despite been on observations using her own phone. Refused to let staff keep her phone.  Again informal - what do people think? Would it be reasonable to keep her phone, or would she have to be sectioned to make this more reasonable? Do personal searches as discussed in the code of practise (MHA) also apply to informal patients?

Thanks any of you guys for any views on these points?  8-)

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Why not Home treatment with Crisis Team?

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Would it be reasonable to keep her phone,

maybe ur trust policy and procedures might have documents regarding ur trust policy.search in ur intranet.if its a phone with a camera then of course she shud not be allowed to keep it.

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If a patient is so sexually disinhibited they have to be on constant obs on the ward then my experience of a crisis team is that they are not going to be able to keep her safe.

With regards to her treatment informally I don't see any problem. Having someone under section gives you the right to detain and treat them but things like obs levels are about manging patients risks on the ward so section status shouldn't matter. You have said that she has capacity and consents and as an informal patient she has the right to leave if she doesn't agree with her treatment.

As far as the phone goes if she is able to make inappropriate phone calls whilst on obs then the way the obs are being carried out needs to be looked at. On wards I have worked on no patients are allowed to keep their own mobile phones, they have to be signed in and out. That is just a ward rule, same for section pts or informal pts.

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On wards I have worked on no patients are allowed to keep their own mobile phones, they have to be signed in and out.

i guess that should be the normal practise in most wards.

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Just to make it more difficult there is also a policy that says that patients aren't allowed mobile phone chargers, even for staff to use for them, as they are an explosion risk.

I wonder what the trust would say if I refused to charge my work phone due to it being an explosion risk?

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haha Paulie where do you work? That policy sounds like it was conceived by a small child!!

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1. If she is in hospital she is no longer HYPOmanic - she is MANIC (ref: DSMIV and ICD 10).

2. Capacity is task-specific and varies temporally - thus needing regular re-evaluation. She might have the capacity to be an informal patient but not have the capacity for something else. It's about the least restricitive option and the patient's best interest. The HTT is NOT an option here - she's on 1:1 for sexual disinhibition!

3. If she still agrees to be on the ward does she understand the ward rules and their consequences? If so - she gets searched if needed and surrenders her phone if asked to. Dems da rules.

4. Electrical equipment (including chargers) are allowed on the ward if passed by the hospital's electrician. Not allowing people access to their relatives sounds like a breach of their human rights to me - unless there is a risk to themselves or others.

5. We do not section people to 'make them more reasonable' - it's not like a pink piece of paper has magical abilities! We use it as a way to ensure patient and public safety, prevent deterioration of disease, and in a patient's best interest. I would speak to this lady at some length - it is quite possible she HAD the capacity to be informal but has lost it now with the deterioration of her mental state. Those phone calls could be doing irrepairable harm to her relationships that she might regret when she is  no longer manic. She had the insight to ask for admission - you need to make this admission a good experience for her and treat her mania rigourously. Act in her best interests.

F_S

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and treat her mania rigourously.

very important. if she is on depakote or something then dont hesitate to titrate it up quickly in 2-3 days.At lower doses it might take ages for her elation and disinhibition to be controlled.

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and treat her mania rigourously.

very important. if she is on depakote or something then dont hesitate to titrate it up quickly in 2-3 days.At lower doses it might take ages for her elation and disinhibition to be controlled.

Err - mania is controlled in the acute phase by a quality antipsychotic (most evidence for quetiapine ref BOLDER I and II) and work is emerging on Quetiapine +/- Lamotrigine +/- Folic acid (CeQuel). Also Geddes et al will soon be releasing their work on mood stabilisers.

Antipsychotics for the short term, mood stabilisers for the medium and long term, ECT for exhaustion/catatonia.

F_S

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agree with antipsychotics F_S.just mentioned rapid titration as sometimes we tend to make the mistake of waiting for a while to c bfore upping it further. never heard about Cequel.interesting. :)

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1) Treat her vigorously

2) depakote is widely prescribed but is not as good for relapse prevention.

3) see if you can get her to start on combination of Lithium and Lamotrigine, as mood stabilizers and in the meanwhile give her Risperidone quicklets.

My experience comes from an inner city London based, management of PICU patients.

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but addict isnt lamotrigine better in depression phase rather than the manic phase. :)

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Lamotrigine in combination with lithium is fantastic for manic phase. I do remember reading lamotrigine being good for depressive phase, though I cant recall clearly whether that is Lamotrigine in combination with Lithium.

In last 4 months must have admitted at least 12 acutely disturbed Bipolar patients and they all responded very well to Lithium and Lamotrigine combo. When I started the post, I would start people on Olanzapine, depakote ec etc but my consultant convinced me into this combination and now I recommend it, when we are called upon for management plans for disturbed patients with Bipolar on general acute wards.

Try this and let me know ! Lot of systematic reviews for this.

For Risperidone , no need for 1, 2 ...Start on 2mg bd and then next day 3 mg BD and push it upto 16 mg , obviously it would vary with each patient.

Ours is the only PICU ward for the entire trust, so there is lot of pressure to keep creating beds.

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Lamotrigine in combination with lithium is fantastic for manic phase. I do remember reading lamotrigine being good for depressive phase, though  I cant recall clearly whether that is Lamotrigine in combination with Lithium.

In last 4 months must have admitted  at least 12 acutely disturbed  Bipolar patients and they all responded very well to Lithium and Lamotrigine combo. When I started the post, I would start people on Olanzapine, depakote ec etc but my consultant convinced me into this combination and now  I recommend it, when we are called upon for management plans for disturbed patients with Bipolar on general acute wards.

Try this and let me know ! [highlight]Lot of systematic reviews for this.

For Risperidone , no need for 1, 2 ...Start on  2mg bd and then next day 3 mg BD and push it upto 16 mg[/highlight] , obviously it would vary with each patient.

Ours is the only PICU ward for the entire trust, so there is lot of pressure to keep creating beds.  

No evidence for risperidone > 8mg - NONE.

All you are doing is using it as a chemical tranquiliser.

Evidence for Lamotrigine is terrible - look at the metaanalysis (not the one from the manufacturer) - the overall effect is very very slightly positive.

Whether there is 'bed pressure' or not we're here to help people not sort out artificially created bed pressure - the solution is better use of resources and proper hospital funding NOT rushing patients through using heroic doses of antipsychotics.

Do you do ECGs on your patients?

F_S

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personally i dont like upping the dose of risperidone above 6 mg/day eventhough the bnf max is 16.

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1. I agree with FS - she is manic (not hypomanic)

2. Regarding her medication  management: it totally depends on the current treatment she is on... or past treatment she has responded to.... and the cause for her current relapse...

eg: if it is a breakthrough, what is the cause? is there issues regarding non compliance.... etc etc...  

3. The above based on the idea that this patient is a known case and has been treated in the past....

If not... just follow the nice guidelines....

I am sorry but you cant just start people on a combination of Lithium and Lamotrigine just like that.... you have to follow some evidence based guidelines... (you dont have to... but it will be wise if something goes wrong...) and I suspect PICU managements can be a bit too aggressive....

If you want it Inner city Indian style PICU... Haloperidol 10mg im TDS; Phenergan 25mg im TDS... Once the patient starts taking oral... Haloperidol 10mg TDS; Pacitane 2mg TDS.... and then start on Lithium 300mg TDS or in a single dose of 900 mg for 5 days and do levels... and titrate...

as person calms down, reduce haldoperidol to lower doses... (maintain at around 10 mg daily along with Lithium initially and then can stop gradually)

Patient back home and working in 15 days.... call that rehabilitation...

Obviously this may not be suitable here.... so just follow NICE guidelines...  :)

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Patient back home and working in 15 days.... call that rehabilitation...

:lol: :lol: :)

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addict: with your lithium/lamotrigine combo, how quick do you titrate up the lamotrigine? If you're using it for acute mania, I would have thought it would need to be at a good dose, so do you push it up quickly? Or does 25mg suffice?

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Lamotrigine doesnt work, full stop.

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[highlight]

1. If she is in hospital she is no longer HYPOmanic - she is MANIC [/highlight](ref: DSMIV and ICD 10).

I dont agree with that statement, hypomanics can be admitted to hospital for various other reasons.

Mere being in hospital should not be inferred as severe or complete disruption of work or social activities IMO.

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[highlight]

1. If she is in hospital she is no longer HYPOmanic - she is MANIC [/highlight](ref: DSMIV and ICD 10).

I dont agree with that statement, hypomanics can be admitted to hospital for various other reasons.

Mere being in hospital should not be inferred as severe or complete disruption of work or social activities IMO.

You are of course entitled to your opinion HOWEVER:

DSMIV criteria for hypomania:

E) The mood disturbance not severe enough to cause marked impairment in social or occupational functioning, or to necessitate hospitalization, and there are no psychotic features.

ICD10 criteria:

....but not to the extent that they lead to severe disruption of work or result in social rejection.

And, of course, once admitted it is not possible to continue going to work.

She is MANIC. Of course making the diagnosis is just a tiny part of dealing with the condition but an important part nonetheless - particularly with prognosis and treatment options (BPAD I vs BPAD II vs elevated mood in the context of other illness).

F_S

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