Bipolar Disorder 

Diagnosis per DSM-5

  • Bipolar I

    • At least one manic episode lasting ≥ 1 week required

    • Hypomanic and major depressive episodes commonly occur, but are not required for diagnosis

  • Bipolar II

    • No history of manic episodes

    • At least one hypomanic episode lasting ≥ 4 days and one major depressive episode required

  • Manic episode: Increased activity + abnormally elevated, expansive, or irritable mood + at least 3 of the following:

    • Distractibility

    • Indiscretion: Increased spending, sexual activity, substance use, etc.

    • Grandiosity

    • Flight of ideas

    • Activity increase

    • Sleep deficit

    • Talkativeness (pressured speech)

  • Hypomanic episode: Diagnosis is similar to manic episode, but symptoms are less severe, i.e.

    • Self esteem is inflated, but not grandiosity does not occur. Social functioning may be improved.

    • More organized and often productive. For example, Ernest Hemingway produced most of his works during hypomanic episodes.

    • Risk-taking behavior is generally not illegally and does not produce long-lasting consequences.

    • Does not require hospitalization.

Treatment: Important to prevent kindling phenomenon (untreated mood transitions leading to rapid cycling) and suicide

  • Lithium

    • Considerations

      • Contraindicated in pregnancy (Ebstein abnormality)

      • May adversely affect renal (irreversible) and thyroid function (reversible)

      • May produce arrhythmias (rare)

    • Initiating treatment

      • Stop all NSAIDs and diuretics

      • Obtain baseline BMP, TSH, T4, and EKG

      • Start 300 mg TID and obtain lithium level within 5 days of starting mediation; goal 1.0 +/- 0.2 mEq/L

    • Obtain BMP, TSH, T4 every 6 months for monitoring

  • Valproic acid (anti-convulsant)

    • Especially effective for rapid cycling bipolar disorder

    • Potentially hepatotoxic: Obtain CMP prior to initiating therapy

    • Start 30 mg/kg/day and adjust every 3 days to achieve desired effect (maximum daily dose 60 mg/kg/day)

    • Obtain valproic acid level once symptoms controlled are controlled (goal 50-100 mcg/mL)

  • Consider atypical antipsychotics, e.g. quetiapine that treat both mania and depressive symptoms

    • Start quetiapine (Seroquel) 100 mg BID

      • Increase quetiapine dose daily by 100 mg qhs until patient is taking 400 mg daily (i.e. 100 mg qAM, 300 mg qhs)

      • Once taking 400 mg daily, may increase by 25 mg/day to maximum daily dose of 800 mg

    • Obtain yearly lipid panel and HbA1c for monitoring

    • Although less common with atypical antipsychotics, monitor for neuroleptic malignant syndrome