I get what you're saying but I also get the hesitation to start tegretol in a 60 year old , as you know, tegretol interacts with tons of medications including itself. It's kind of a nightmare if patient is on important non-psychiatric medications managed by cardiology, etc.
Isn't this a contradiction? Not trying to assign any blame, and maybe things work differently in my state vs. other states, but who admits a delusional manic patient voluntarily? The patient isn't going to have the capacity to understand their illness. I can only talk generally here, but based on this limited information, if patient continued to refuse lithium or depakote (and it is medically safe for them to take one), I would tend to make the patient involuntary, testify in court, give IM backup of small dose of zyprexa if refusal of oral depakote or lithium.
What?? If someone is paranoid that their family is conspiring against them, and gets agitated over something as minor as someone doubting whether he knows famous people that he doesn't actually know, I feel really, really bad about their safety outpatient.
There's a lot of missing information so I don't want to speculate too much, but from what I am reading, discharging this patient at this stage of illness is at best is a disservice to the patient, their family, and their outpatient psychiatrist, and may prove to be downright dangerous.
Manic patients notoriously lack insight (such as failing to recognize that they are displaying signs of illness) and display poor judgment (such as stopping meds and refusing suggested meds) and the patient is still displaying signs of mania -- pressured speech, tangentiality, delusions, situational agitation. Are the delusions long standing for years? If this is their baseline, would they not need guardianship?
I would be interested to hear whether anyone believes that benzodiazepines have inherent anti-manic properties, besides simply their sedative effects.
you're using a fair amount of ifs to come to this conclusion regarding forcing someone to be hospitalized in a non-medically necessary way.
Saying that someone is "voluntary" because "they don't want to be involuntary" is incredibly misleading. That's involuntary but without the requisite paperwork. It's an abuse of our power as psychiatrists to trick patients into saying they're voluntary to avoid the consequences of being involuntary. If they're voluntary that implies no coercion. No "if you don't sign in as voluntary I will fill out involuntary paperwork." None of that "if you accept PO then I won't stab you with an IM, but if you refuse the PO I will pin you down and stab you." That's coercive. It's clearly coercive. Same thing with "shows of force" that involve having two big techs stand next to you and block the patient in the room while they're being confronted.
Paranoia is incredibly common in outpatient settings. Any psychiatrist who honestly believes they don't discharge people with residual paranoia is either a fool or lying. While paranoia increases risk for violence it is not in itself adequate to justify an admission. If it were then there would be no chronic psychosis in outpatient settings. Paranoia tends to resolve over time, and forcing someone to stay in a fabricated setting like a hospital does not help them resolve their paranoia that will resume the second they are around family members. This is one of the major reasons that extended hospitalization simply aren't justifiable (to insurance or within our society in general) for the overwhelming majority of people with paranoia.
Indication for prolonged hospitalization is rather straightforward: risk of harm to self or others is not reasonably mitigated yet but continued hospitalization will mitigate this risk. So someone with paranoia AND homicidal ideation with intent and plan would qualify but paranoia while taking care of oneself and not having active thoughts of harming people is far more likely to be an outpatient problem. Someone who just can't take care of themselves at all will likely qualify.
Tricking someone into being a voluntary patient for longer than is medically necessary has many ethical drawbacks. As a physician billing for services you are directly profiting off of this abuse of power. The patient is put in an uncomfortable place where they don't want to defy the doctor, meaning they may be on the hook for $20k+ in charges after their insurance stops paying. I'd say this would contribute a fair amount more to potential acting out than being allowed to return to their home.
It's important to educate the patient and family regarding low expressed emotion and avoiding arguments. If the family is going to argue with the patient repeatedly in an emotionally charged way then they need to be told that is counterproductive. It doesn't matter how many drugs you give someone or how long you lock them up, if the family will instigate then that person will be at risk for decompensation. Which is better long-term: having someone spend 20 minutes talking to the family about this or forcing another day of hospitalization?
As for going above and beyond 20 mg of Zyprexa per day: as long as it's being tolerated that's fine. I've talked before about my experience with 40-60 mg per day of Zyprexa with chronic inpatients in a forensic state hospital setting. There is a very small minority who benefit from doses above 20 mg per day for extended periods of time. Usually these are people who one might suspect of being rapid metabolizers: the effect seems to really wear off in 6-8 hours requiring BID or TID dosing, they never seem sedated, or they aren't gaining weight. Sometimes there are the people who didn't gain weight at 20 but did at 45 per day, but they really do have much better symptom control at 45. Sadly, in my experience, most of the people who go up to 40, 45, or 60 mg per day didn't have an opportunity to respond at 20, 15, 10, or even 5 mg per day. 2 weeks is a long time and there's literature to back up increasing that early, but there's also a ton of experience that says that after 3 months 20 mg really might have done just as great a job as bumping it up higher did. It's important to remember to try decreasing back to 20 mg after a short while to make sure the patient isn't being chronically overmedicated.
There's also some great merit for short-term use of higher doses of Zyprexa (starting at 60 for a few days, then down to 45, then 40, then 30, then 20 with the plan to stay at 20 mg long-term). This is usually for patients who aren't sleeping, who aren't caring for themselves, or who are actively homicidal with repeated attempts to act on those urges. Not residual paranoia and grandiosity in someone who's eating, sleeping, and not getting into fights.
