Skip to content

Bipolar I Disorder

Basics

  • Episodic mood disorder with ≥1 manic or mixed episode
  • Causes marked impairment, psychosis, or hospitalization
  • Symptoms not due to substance or medical condition

Epidemiology

  • Typical onset: 15–30 years (average 25 years)
  • Lifetime prevalence: 1–1.6%
  • Manic episodes more common in men; depressive episodes more common in women

Etiology and Pathophysiology

  • Dysregulation of neurotransmitters: serotonin, norepinephrine, dopamine
  • MRI shows abnormalities in prefrontal cortex, striatum, amygdala
  • Genetics:
  • Monozygotic twin concordance 40-70%
  • Dizygotic twin concordance 5-25%
  • 50% have at least one parent with mood disorder

Risk Factors

  • Family history of mood disorders
  • Substance abuse (60%)
  • ADHD, anxiety disorders (~50%)
  • Eating disorders

Diagnosis

History

  • Collateral information essential
  • Assess for safety concerns: suicidal/homicidal ideation, psychosis
  • Look for symptoms: decreased sleep, risky behavior, impulsivity, talkativeness
  • Substance use history and timing relative to mood episodes

Mental Status Exam (Acute Mania)

  • Appearance: disorganized, psychomotor agitation, bright clothing
  • Speech: pressured, difficult to interrupt
  • Mood/Affect: euphoria, irritability, expansive, labile
  • Thought process: flight of ideas, distractibility
  • Thought content: grandiosity, paranoia, hyperreligiosity
  • Perceptual abnormalities common (delusions)
  • Poor insight and judgment
  • Mixed episodes: manic and depressive symptoms simultaneously

Differential Diagnosis

  • Psychiatric: unipolar depression with psychosis, schizophrenia, schizoaffective, personality disorders, ADHD, substance-induced mood disorder
  • Medical: epilepsy (temporal lobe), brain tumor, infections (AIDS, syphilis), stroke, endocrine disorders, multiple sclerosis
  • Children: differentiate from ADHD, ODD

Diagnostic Tests & Interpretation

  • Mood Disorder Questionnaire (screening for bipolar)
  • Patient Health Questionnaire-9 (PHQ-9) for depression severity
  • Labs: TSH, CBC, BMP, B12, LFTs, RPR, HIV, ESR
  • Drug/alcohol screen at each presentation
  • Brain imaging (CT/MRI) if new onset mania or psychosis, especially in elderly
  • EEG if suspect temporal lobe epilepsy

Treatment

General Measures

  • Ensure safety
  • Maintain regular sleep schedule
  • Avoid substances
  • Exercise, healthy diet
  • Psychotherapy: CBT, social rhythm, interpersonal therapy for depression

Medications

Acute Mania (First Line)

  • Lithium monotherapy
  • Atypical antipsychotics (quetiapine, risperidone/paliperidone, aripiprazole, asenapine, cariprazine)
  • Divalproex sodium
  • Combination: lithium or divalproex + atypical antipsychotic

Acute Mania (Second Line)

  • Olanzapine, carbamazepine
  • Lithium plus divalproex or olanzapine
  • Ziprasidone, haloperidol, cariprazine
  • Electroconvulsive therapy (ECT)

Acute Bipolar Depression (First Line)

  • Quetiapine
  • Lithium, lamotrigine, lurasidone, cariprazine

Acute Bipolar Depression (Second Line)

  • Divalproex, lumateperone
  • Bupropion adjunctive
  • Olanzapine + fluoxetine
  • ECT

Medication Monitoring

  • Lithium: monitor plasma levels (0.8-1.2 mmol/L), renal, thyroid function
  • Divalproex: CBC, LFTs; avoid in pregnancy (Category D)
  • Carbamazepine: CBC, LFTs; avoid with TCAs and MAOIs; Category D
  • Atypical antipsychotics: monitor for metabolic syndrome, EPS, prolactinemia
  • Avoid TCAs and SNRIs (may worsen cycling)

Issues for Referral

  • Multidisciplinary approach including PCP, psychiatrist, therapist

Additional Therapies

  • Light therapy, transcranial magnetic stimulation, ketamine infusion (modest evidence)
  • Blue-blocking glasses or dark therapy for mania
  • Regular sleep/wake schedule recommended

Admission and Nursing Considerations

  • Involuntary admission if danger to self/others or inability to meet basic needs
  • Nursing: alert for agitation or suicidality, continuous observation if suicidal

Ongoing Care

  • Regular scheduled visits to ensure adherence
  • Mood charting recommended
  • Frequent communication between care team

Diet

  • Omega-3 fatty acids and probiotics (limited evidence)

Patient Education

  • National Alliance on Mental Illness (NAMI): https://www.nami.org/
  • National Institute of Mental Health (NIMH): https://www.nimh.nih.gov/
  • International Bipolar Foundation (IBPF): https://ibpf.org/

Prognosis

  • Relapse risk related to medication adherence, sleep, and support
  • 40-50% relapse with another manic episode within 2 years
  • 25-50% attempt suicide; 15% complete suicide
  • Poor prognosis: substance abuse, unemployment, psychosis, depression, male sex