From the Guidelines
The DSM-5 criteria for bipolar disorder prioritize the presence of manic or hypomanic episodes, with specific duration and symptom requirements, to guide diagnosis and treatment. According to the DSM-5, bipolar I disorder requires at least one manic episode lasting at least one week, while bipolar II disorder involves at least one hypomanic episode and one major depressive episode 1. The DSM-5 also recognizes cyclothymic disorder, characterized by numerous periods of hypomanic and depressive symptoms lasting at least two years. For diagnosis, symptoms must cause significant distress or impairment and not be attributable to substance use or medical conditions.
In the context of children and adolescents, the assessment and treatment of bipolar disorder can be complex, with studies suggesting that juvenile mania often presents with symptom patterns that vary from classic descriptions of bipolar disorder in adults, including irritability, belligerence, and mixed manic-depressive features 1. The PEA-BP phenotype, characterized by chronic continuous rapid cycling, long durations of episodes, and a high rate of ADHD, may be similar to youths described as having chronic baseline mania 1.
Treatment of bipolar disorder typically involves mood stabilizers, such as lithium, valproate, or lamotrigine, often combined with atypical antipsychotics, as well as psychotherapy, particularly cognitive behavioral therapy and interpersonal therapy 1. Medication adherence is crucial to prevent relapse and maintain stability, with treatment plans tailored to the individual's specific needs and symptom profile. In real-life clinical practice, prioritizing the most recent and highest-quality evidence, such as the DSM-5 criteria, is essential for guiding diagnosis and treatment decisions, while also considering the unique needs and circumstances of each patient.
Key considerations in the diagnosis and treatment of bipolar disorder include:
- Presence of manic or hypomanic episodes
- Duration and symptom requirements
- Significant distress or impairment
- Attribution to substance use or medical conditions
- Individualized treatment plans
- Medication adherence and stability.
From the Research
DSM-5 Criteria for Bipolar Disorder
The DSM-5 criteria for bipolar disorder include recurrent episodes of depression and mania or hypomania 2. Bipolar depressive episodes are similar to major depressive episodes, while manic and hypomanic episodes are characterized by a distinct change in mood and behavior during discrete time periods.
Diagnosis and Treatment
Diagnosis and optimal treatment of bipolar disorder are often delayed by a mean of approximately 9 years following an initial depressive episode 2. Long-term treatment consists of mood stabilizers, such as lithium, valproate, and lamotrigine, as well as antipsychotic agents like quetiapine, aripiprazole, asenapine, lurasidone, and cariprazine 2, 3.
Key Points
- Bipolar disorder affects approximately 8 million adults in the US and approximately 40 million individuals worldwide 2.
- The age of onset is usually between 15 and 25 years, and depression is the most frequent initial presentation 2.
- Approximately 75% of symptomatic time consists of depressive episodes or symptoms 2.
- Lithium and valproate are commonly used in the treatment of bipolar disorder, with lithium being effective in treating acute mania and preventing both manic and depressive episodes 4.
- Valproate may be more effective as an antimanic rather than prophylactic agent 4.
Treatment Options
- First-line therapy includes mood stabilizers, such as lithium, anticonvulsants, such as valproate and lamotrigine, and atypical antipsychotic drugs, such as quetiapine, aripiprazole, asenapine, lurasidone, and cariprazine 2.
- Combination therapy and adjunctive psychotherapy may be necessary to treat symptoms across different phases of illness 3.
- Antidepressants are not recommended as monotherapy, as they may be associated with mood destabilization, especially during maintenance treatment 5.