LIMITATIONS OF AN OUTPATIENT COMMITMENT IN A GERIATRIC PATIENT WITH LATE-LIFE MANIA

Abstract

Introduction The prevalence of mania among >65-year-olds ranges from 0.1% to 0.4% and its treatment poses several challenges for clinicians. Aside from the challenges posed when selecting a medication, there is also the challenge of patients lacking insight into their illness. This can be a specific challenge for geriatric patients who have not had previous psychiatric diagnoses and struggle with adjusting with a diagnosis of bipolar disorder which is associated quite often with shame and denial. This can often lead to involuntary inpatient commitment and court ordered medications but also an outpatient commitment process. In this case, we discuss the limitations of enforcing the outpatient commitment process with a patient who presented with late life mania. Methods This case report focuses on a geriatric patient with corticosteroid-induced mania who was first seen and treated in the inpatient psychiatric hospital and then was followed in an outpatient resident geriatric clinic. Patient's clinical documents were reviewed both in the inpatient setting and outpatient setting. A literature survey was performed on the topics of corticosteroid-induced mania, involuntary commitment process, and outpatient commitment process as well as ethical considerations involved regarding involuntary commitment and court- ordered medications. Results A previously healthy, 75 year old Caucasian male was acutely hospitalized in an inpatient psychiatric hospital after presenting with manic symptoms with psychosis after taking prednisone prescribed for his rheumatoid arthritis. The patient displayed poor insight into his symptoms and refused medications. Involuntary hospitalization was pursued as well as court- ordered medications. The patient agreed to take his medications but continued to demonstrate poor insight into his illness. Based on concerns from his providers as well as his family, the patient was placed on an outpatient commitment to help with treatment adherence, and he was seen in geriatric psychiatry resident clinic. He would present for appointments but was self-titrating doses of medications and had discontinued his antipsychotic medication. Through this case, more knowledge was gained about the limitations of the outpatient commitment process and how its effectiveness is not as robust as an inpatient commitment. This patient eventually discontinued all treatment and terminated care with the clinic. Conclusions The involuntary outpatient commitment process was put in place to allow patients who lacked insight into their mental illness to access psychiatric care. There has been much discussion about the ethical principles of beneficence and autonomy that are pitted against each other when discussing the outpatient commitment process, but the hope is that this process helps providers to care for patients especially geriatric patients who are diagnosed with late-life bipolar disorder and may lack the insight with being diagnosed with a psychiatric illness. However, from treating this patient, we have come across challenges that exist with implementing and enforcing the outpatient commitment process. This warrants a discussion on the limitations it poses and what are the other strategies that we can implement to continue treating this population.