Bipolar disorder is a recurrent and sometimes chronic mental illness marked by alternating periods of abnormal mood elevation and depression associated with a change or impairment in functioning.
The long-term course of illness is characterised by a predominance of depression, although a history of at least one manic, hypomanic, or mixed episode is required to make the diagnosis of a bipolar disorder.
Diagnosis is based on interviews with the patient and family, using diagnostic criteria for bipolar disorder.
Misdiagnosis of bipolar disorder is common, with unipolar major depressive disorder the most frequent diagnostic error made.
The management of acute mania requires mood stabilisers or atypical antipsychotics, as monotherapy or in combination. There are fewer approved treatment options for acute bipolar depression; traditional antidepressants are not indicated.
Bipolar disorder requires an individualised long-term management plan that includes maintenance medication(s), adjunctive psychosocial therapies, careful monitoring for any treatment-emergent complications, and promotion of a healthy lifestyle including sleep hygiene, exercise, and stress management.
Bipolar disorder, previously termed manic depression, is a psychiatric diagnosis characterised by abnormally elevated or irritable mood episode(s) accompanied by disruptive symptoms of distractibility, indiscretions, grandiosity, flight of ideas, hyperactivity, decreased need for sleep, and talkativeness. It is marked by alternating mood elevation (mania or hypomania) and depression. Manic episodes include a clustering of these symptoms over at least a period of 1 week, and are more disruptive than hypomania (milder symptoms, >4 days' duration).
History and exam
Key diagnostic factors
- presence of risk factors
- major depressive episode(s)
- episode(s) of manic or mixed episodes
- episode(s) of hypomania
- inflated self-esteem or grandiosity
- decreased need for sleep
- more talkative than usual, or feels pressure to keep talking
- flight of ideas, or subjective experience that thoughts are racing
- increase in goal-directed activity or psychomotor agitation
- excessive involvement in pleasurable activities that have a high potential for adverse consequences
- functional impairment
- no substance misuse
- no underlying medical cause
- not due to somatic antidepressant treatment or other prescribed medication
- family history of bipolar disorder
- onset of mood disorder prior to 20 years of age
- stressful life events
- previous history of depression
- lifetime history of a substance misuse disorder
- presence of an anxiety disorder
- cardiovascular disease
1st investigations to order
- Primary Care Evaluation of Mental Disorders (PRIME-MD)
- Patient Health Questionnaire (PHQ-9)
- Mood Disorder Questionnaire (MDQ)
- Composite International Diagnostic Interview (CIDI)
- Bipolarity Index
- Young Mania Rating Scale (YMRS)
- thyroid function tests
- serum vitamin D
- toxicology screen
Investigations to consider
- fasting lipid profile
- fasting glucose
- MRI brain
not rapid cycling with acute mania, hypomania, or mixed: non-pregnant
not rapid cycling with acute bipolar I depression: non-pregnant
not rapid cycling with acute bipolar II depression: non-pregnant
rapid cycling: non-pregnant
bipolar I after stabilisation of acute episode: non-pregnant (including rapid cycling and mixed features)
bipolar II after stabilisation of acute episode: non-pregnant
after stabilisation of acute episode: pregnant
Sudhakar Selvaraj, MBBS DPhil MRCPsych
Assistant Professor of Psychiatry
University of Texas Health Science Center
SS has received speaking honoraria from Global Medical Education and honoraria from the British Medical Journal Publishing Group. He owns convertible shares at Flow MedTech, Inc (a medical device start-up company). He has been involved in a treatment-resistant depression clinical trial and received research support from COMPASS pathways (a mental healthcare company).
Dr Sudhakar Selvaraj would like to gratefully acknowledge Dr Prashant Gajwani and Dr David J. Muzina, previous contributors to this topic.
PG has served on the speakers' bureau for Merck and Sunovion. DJM is an author of a number of references cited in this topic. DJM has previously received honoraria for research support from Repligen Co. He has also previously received honoraria as a speaker and/or advisor from AstraZeneca, Pfizer, BMS, Wyeth, Sepracor, and GSK. DJM is a full-time employee of Medco.
Roger McIntyre, MD
Mood Disorders Psychopharmacology Unit
University Health Network
Associate Professor of Psychiatry and Pharmacology
University of Toronto
RM has received research funds from Stanley Medical Research Institute and National Alliance for Research on Schizophrenia and Depression (NARSAD). RM is on the advisory boards for AstraZeneca, Bristol-Myers Squibb, France Foundation, GlaxoSmithKline Janssen-Ortho, Solvay/Wyeth, Eli Lilly, Organon, Lundbeck, Biovail, Pfizer, Shire, and Schering-Plough. RM is on the speakers' bureau for Janssen-Ortho, AstraZeneca, Eli Lilly, Lundbeck, Biovail, and Wyeth. RM has received research grants from Eli Lilly, Janssen-Ortho, and Shire.
Jan Scott, MBBS
Professor of Psychological Medicine
University of Newcastle
Psychological Treatments Research
Institute of Psychiatry
University Department of Psychiatry
Royal Victoria Infirmary
Newcastle upon Tyne
JS has received remuneration for attending advisory boards for AstraZeneca, BSM-Otsuka, Eli Lilly, GSK, and Sanofi-Aventis.
- Mood disorder due to general medical condition
- Substance-induced mood disorder
- Major depressive disorder
- Bipolar disorder: assessment and management
- The World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for the biological treatment of bipolar disorders: acute and long-term treatment of mixed states in bipolar disorder
Bipolar disorder: what is it?
Bipolar disorder: what medicines work?More Patient leaflets
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