Bipolar Disorder

Mood disorder characterized by changes in mood, sleep, energy, and cognition
Diagnosis may be delayed 6-8 years
Highest suicide rate of any psychiatric disorder, 20x higher than general population

Abnormally and persistently elevated, expansive, or irritable mood, along with abnormally increased activity or energy, present for >1 week or requiring hospitalization, possibly including psychotic features

>3 of the following symptoms:
Inflated self-esteem or grandiosity
Decreased need for sleep or feeling rested after only a few hours of sleep
Increased quantity of speech or speech that is pressured
Flight of ideas or subjective racing thoughts
Easily distracted, may be in social situations, work, or school
Increased goal-directed activity or psychomotor agitation
Engaging in activities that can result in detrimental outcomes (spending, sex, drugs, etc.)

A period of abnormally and continually elevated, expansive, or irritable mood with increased activity or energy for > 4 consecutive days, not including psychotic features. Not as severe as mania.

At least 1 manic episode

At least one hypomanic and one depressive episode, with no history of manic episode

Manic/hypomanic episode, with mixed features:
Full criteria of manic/hypomanic episode + > 3 symptoms of depression OR
Full criteria for both manic and depressive episode

Depressive episode, with mixed features:
Full criteria of depressive episode + > 3 symptoms of mania/hypomania

> 4 mood episodes have occurred within previous 12 months, mania, hypomania, or depressive
Separated by partial or full remission for > 2 months or there is switch to opposite polarity not caused by substance

Delusions or hallucinations present at any time during an episode
may be mood congruent or mood incongruent

Mood symptoms occur during pregnancy or within 4 weeks after delivery

Seasonal pattern of greater than or equal to 1 type of mood episode with no non-seasonal episodes of that polarity for at least the previous 2 years

Distractibility
Indiscretions (excessive pleasure activities)
Grandiosity
Flight of ideas
Activity increase
Sleep deficits
Talkativeness

11-item, clinician-rated
Assesses mood, motor activity, sexual interest, sleep, language, appearance, insight, speech, thought content, disruptive behavior

Genetics:
7x increased risk with first-degree relative
50% of patients have family history

Childhood risk factors: trauma, abuse, anxiety, subsyndromal conduct disorder

Risk factors associated with a switch from depression to bipolar disorder:
Rapid or early onset depression symptoms
Substance use disorder
≥4 depressive episodes

Previous psychiatric hospitalization
Female
Bipolar II disorder
Mixed episode
Comorbid substance use disorder, eating disorder, or personality disorder

episodes may become more frequent and difficult to treat with each episode, important to treat early and effectively

Adequate sleep, sleep deprivation may contribute to manic or depressive symptoms
Psychotherapy (adjunct)
ECT
Bright light therapy (adjunct), may improve remission rates of bipolar depression, but possible risk of switching to mania/hypomania

Rapid control of behavioral symptoms, sleep restoration, mood stabilization

After mood stability has been achieved for 3 months:
Continued improvement of functioning
Prophylaxis against future mood episodes
May initially include medications used in acute treatment, goal of monotherapy

Antidepressants should be tapered and discontinued when possible
no demonstrated benefit in depressive symptoms
if used, then use in combination with a mood stabilizer

Lithium
Valproic acid (VPA)
Second generation antipsychotic (SGA)
Lithium + SGA
VPA + SGA
Monotherapy preferred, but may utilize two agents with severe episodes or if psychotic features present

Alternative first-line agent
CBZ (carbamazepine)
Haloperidol

Combinations of first- and second-line agents
Clozapine
Oxcarbazepine (OXC)

VPA
Carbamazepine (CBZ)
SGA
(Lithium not effective for mixed episodes)

Alternative first-line agent
Carbamazepine (CBZ)
Haloperidol

Combinations of first- and second-line agents
Clozapine
Oxcarbazepine (OXC)

Lithium
Lamotrigine
Quetiapine IR or ER
Lurasidone
Olanzapine/fluoxetine
Limited data: VPA, CBZ
Bipolar I: Consider combination of lithium + VPA

Alternative first-line agent
Combination of 2 first-line agents (not 2 SGAs)

Different combinations of 2-3 agents
Augmentation with:
Antidepressant (not paroxetine)
ECT
Modafanil (limited data)

Continuation of medication used to treat manic/depressive episode
Lithium
Lamotrigine (limited efficacy in preventing mania)
Quetiapine, olanzapine, LAI risperidone

Lithium + VPA or lamotrigine
CBZ
Alternative SGA

treatment of bipolar disorder is lifelong unless there is a complication with using medication