Bipolar disorder in adults

Last reviewed: 1 Nov 2022
Last updated: 15 Dec 2020



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
  • distractibility
  • 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
More key diagnostic factors

Risk factors

  • 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
  • obesity
  • cardiovascular disease
More risk factors

Diagnostic investigations

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)
  • FBC
  • thyroid function tests
  • serum vitamin D
  • toxicology screen
More 1st investigations to order

Investigations to consider

  • fasting lipid profile
  • fasting glucose
  • MRI brain
  • actigraphy
More investigations to consider

Treatment algorithm


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.

Peer reviewers

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

Honorary Professor

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.

  • Differentials

    • Mood disorder due to general medical condition
    • Substance-induced mood disorder
    • Major depressive disorder
    More Differentials
  • Guidelines

    • 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
    More Guidelines
  • Patient leaflets

    Bipolar disorder: what is it?

    Bipolar disorder: what medicines work?

    More Patient leaflets
  • padlock-lockedLog in or subscribe to access all of BMJ Best Practice

Use of this content is subject to our disclaimer