Bipolar disorder is characterised by recurrent episodes of depression and mania or hypomania. The symptoms often start at a younger age (under 25 years). It has a particularly high rate of suicide.
Depressive episodes feature low mood, anhedonia and low energy and can be severe.
Manic episodes involve excessively elevated mood and energy, significantly impacting their normal functions (e.g., caring and work responsibilities).
Hypomanic episodes involve milder symptoms of mania without having a significant impact on their function.
Mixed episodes can involve a mix of symptoms or rapid cycling between mania and depression.
Features of Mania
Potential features of mania include:
- Abnormally elevated mood
- Significant irritability
- Increased energy
- Decreased sleep (sometimes going days without sleeping)
- Grandiosity, ambitious plans, excessive spending and risk-taking behaviours
- Disinhibition and sexually inappropriate behaviour
- Flight of ideas (rapidly generating and jumping between ideas)
- Pressured speech (rapid and unrelenting speech)
- Psychosis (delusions and hallucinations)
Diagnosis
Diagnosis is made by a specialist, based on the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).
Bipolar I disorder involves at least one episode of mania.
Bipolar II disorder involves at least one episode of major depression and at least one episode of hypomania.
Cyclothymia involves milder symptoms of hypomania and low mood. The symptoms are not severe enough to significantly impair their function.
Unipolar depression refers to when the person only has episodes of depression, without hypomania or mania.
Acute Episode Management
Secondary care specialists should manage acute episodes of bipolar disorder. Patients require a referral for an urgent mental health assessment or hospital admission.
Treatment options for an acute manic episode (as per the NICE guidelines updated 2023) include:
- Antipsychotic medications (e.g., olanzapine, quetiapine, risperidone or haloperidol) are first-line
- Other options are lithium and sodium valproate
- Existing antidepressants are tapered and stopped
Treatment options for an acute depressive episode (as per the NICE guidelines updated 2023) include:
- Olanzapine plus fluoxetine
- Antipsychotic medications (e.g., olanzapine or quetiapine)
- Lamotrigine
Long-Term Management
Lithium is the usual long-term treatment.
Serum lithium levels (taken 12 hours after the most recent dose) are closely monitored to ensure the dose is correct. The usual initial target range is 0.6–0.8 mmol/L. Lithium toxicity can occur if the dose and levels are too high.
Notable potential adverse effects of lithium include:
- Fine tremor
- Weight gain
- Chronic kidney disease
- Hypothyroidism and goitre (it inhibits the production of thyroid hormones)
- Hyperparathyroidism and hypercalcaemia
- Nephrogenic diabetes insipidus
Alternatives to lithium for long-term treatment include sodium valproate and olanzapine.
Lasting power of attorney and advanced decisions can be helpful, particularly for future episodes of mania where the person’s judgement and decision-making may be impaired, resulting in harmful outcomes (e.g., excessive spending or gambling).
TOM TIP: Sodium valproate is teratogenic. It can cause neural tube defects and developmental delay if used in pregnancy. There are strict rules for avoiding sodium valproate in females with childbearing potential unless there are no suitable alternatives and strict criteria are met. The Valproate Pregnancy Prevention Programme is in place to ensure this happens, which involves ensuring effective contraception and an annual risk acknowledgement form. This has been given much attention over recent years and may be tested in exams.
Last updated June 2024
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