Bipolar disorder is a recurrent and often chronic mental illness marked by episodes of hypomania or mania and depression, associated with a change or impairment in functioning.
The long-term course of illness is characterized 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 the mental status exam at the time of the evaluation and the longitudinal history from the patient and family, using diagnostic criteria for bipolar disorder.
Misdiagnosis of bipolar disorder is common, with depressive disorders, including unipolar major depressive disorder, accounting for the most frequent diagnostic errors.
The management of acute mania, as well as maintenance treatment, requires mood stabilizers or antipsychotics, as monotherapy or in combination. There are fewer approved treatment options for acute bipolar depression; traditional antidepressants alone are not indicated.
Bipolar disorder requires an individualized 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 an episodic mood disorder characterized by manic, or hypomanic, episodes. Two subtypes are recognized: bipolar I disorder and bipolar II disorder.
Bipolar I disorder is characterized by manic episodes, which are distinct periods of abnormally and persistently elevated, expansive, or irritable mood, with abnormally and persistently increased energy or activity, lasting for at least 1 week. Although the lifetime occurrence of a major depressive episode is not a requirement for diagnosis, most people with bipolar I disorder will experience a major depressive episode at some point during their lives.
Bipolar II disorder is characterized by a current or past hypomanic episode and a current or past major depressive episode. Hypomanic episodes present with similar symptoms as mania but cause less impairment and are of shorter duration, lasting for at least 4 consecutive days.
History and exam
Key diagnostic factors
- major depressive episode(s)
- episode(s) of mania
- 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 age 20 years
- stressful life events
- childhood trauma
- 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: nonpregnant
not rapid cycling with bipolar I depression: nonpregnant
not rapid cycling with bipolar II depression: nonpregnant
rapid cycling: nonpregnant
bipolar I after stabilization of acute episode: nonpregnant (including rapid cycling and mixed features)
bipolar II after stabilization of acute episode: nonpregnant
after stabilization of acute episode: pregnant
- 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 medications work?More Patient leaflets
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