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A 45-year-old woman with a 20-year history of a poorly controlled bipolar disorder had been seeing her general practitioner irregularly and now presented to him in a manic state. She had grandiose delusions, was overspending and was constantly harassing the local radio station because she wanted to be allowed to go on air to inform everyone that she was saving the world.

The general practitioner knew her and her family well, and, after a home visit, was able to ascertain that her parents were coping with her and that there was no immediate apparent physical danger to either her or her family.

Management

The general practitioner consulted me, and I assessed the patient and her family at home with him.

A management plan was drawn up in conjunction with the patient and a case manager from the community mental health team. A copy of the plan, signed by all parties including the patient and her parents, was given to the patient. This plan addressed a series of social and psychological needs, as well as the need for regular medication which was to be monitored by a case manager. The plan also stated that if any of the parties to the plan, including the patient, felt that the patient was becoming more unwell then they could ask for a further psychiatric assessment from me, and that the patient would comply with any management changes as a consequence of that assessment.

Further assessment

I undertook two more home assessments in the next three months, one at the request of the general practitioner and one at the request of the patient. One other assessment was performed by videoconferencing as I had moved interstate.

The patient's wishes to remain at home were upheld and the team approach, with the general practitioner and case manager working with the patient and her family, with me acting as a consultant psychiatrist for the whole group, worked successfully.

Follow-up

Over the course of three months the patient's symptoms subsided, she maintained a part-time voluntary job, greatly strengthened her relationship with her general practitioner, and agreed to regular and consistent follow-up and monitoring of her illness by him in future.

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