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Bipolar disorder in adults

Last reviewed: 1 Nov 2023
Last updated: 31 Jan 2023



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
  • 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 age 20 years
  • stressful life events
  • childhood trauma
  • 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)
  • CBC
  • 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: 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



Adrian Preda, MD

Professor of Clinical Psychiatry

University of California, Irvine




AP has received honoraria from Guidepoint and GLG Consulting.


Dr Adrian Preda would like to gratefully acknowledge Dr Sudhakar Selvaraj, Dr Prashant Gajwani, and Dr David J. Muzina, previous contributors to this topic.


SS has received speaking honoraria from Global Medical Education and honoraria from the British Medical Journal Publishing Group; owns convertible shares at Flow MedTech, Inc (a medical device start-up company); and has been involved in a treatment-resistant depression clinical trial and received research support from COMPASS pathways (a mental healthcare company). PG has served on the speakers' bureau for Merck and Sunovion. DJM is an author of a number of references cited in this topic; has previously received honoraria for research support from Repligen Co; has previously received honoraria as a speaker and/or advisor from AstraZeneca, Pfizer, BMS, Wyeth, Sepracor, and GSK; and is a full-time employee of Medco.

Peer reviewers

Stuart Watson, MD, MRCPsych, MBBS

Clinical Senior Lecturer

Newcastle University




SW declares that he has no competing interests.

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 medications work?

    More Patient leaflets
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