What is bipolar disorder?

Bipolar Disorder

Bipolar disorder is characterized by distinct episodes of mania or hypomania alternating with depression, with marked changes in mood, energy, behavior, and sleep patterns, representing significant departures from baseline functioning. 1

Types of Bipolar Disorder

• Bipolar I Disorder: Requires at least one manic episode lasting ≥7 days (or any duration if hospitalization is required). Episodes of depression are not required but commonly occur 2

• Bipolar II Disorder: Characterized by periods of major depression and hypomania (episodes lasting at least 4 days) without full manic or mixed episodes 2

• Bipolar Disorder Not Otherwise Specified (NOS): Used for cases that don't meet full criteria for other bipolar diagnoses, often applied to youths who don't present with classic adult symptoms 2

• Mixed Episode: A period lasting ≥7 days where symptoms of both manic and depressive episodes are present simultaneously 2

Clinical Features

Manic Episodes

• Euphoria or irritability
• Grandiosity
• Racing thoughts
• Pressured speech
• Decreased need for sleep
• Increased goal-directed activity
• Poor judgment
• Aggressiveness
• Possible hostility 3

Hypomanic Episodes

• Similar to mania but less severe
• Last at least 4 days
• Do not cause marked impairment in functioning
• Do not require hospitalization 1

Depressive Episodes

• Similar to major depressive episodes
• Constitute approximately 75% of symptomatic time in bipolar disorder 1, 4

Epidemiology and Course

• Affects approximately 8 million adults in the US and 40 million individuals worldwide 4
• Age of onset typically between 15-25 years 4
• Depression is often the initial presentation 4
• Diagnosis and optimal treatment are frequently delayed by approximately 9 years following initial episode 1, 4
• Early-onset cases (before age 13) are predominantly male 1
• Life expectancy is reduced by 12-14 years 1, 4
• 1.6-2 fold increased risk of cardiovascular mortality 1, 4
• Annual suicide rate is approximately 0.9% (compared to 0.014% in general population) 4
• 15-20% of people with bipolar disorder die by suicide 4

Diagnostic Challenges

• Historically, bipolar disorder in adolescents with psychotic features was often misdiagnosed as schizophrenia 1
• Bipolar symptoms in children may present as chronic difficulties regulating moods, emotions, and behavior rather than clearly demarcated phases 2
• Sleep disturbance, a pathognomonic sign in adults, is present in <50% of juvenile cases 2
• Comorbidities like ADHD and conduct problems can complicate diagnosis 2

Genetic Factors

• Strong genetic component with approximately 70% heritability 1
• Four to sixfold increased risk in first-degree relatives 1
• Bipolar I has closer genetic association with schizophrenia, while Bipolar II is more genetically associated with major depressive disorder 5

Treatment Approaches

Pharmacotherapy

• Mood stabilizers: Lithium is the gold standard with antimanic, antidepressant, and anti-suicide effects 3, 5
• Anticonvulsants: Valproate, lamotrigine, and carbamazepine 4, 5
• Atypical antipsychotics: Quetiapine, aripiprazole, asenapine, lurasidone, and cariprazine 6, 4
• Important caution: Antidepressants are not recommended as monotherapy and may cause mood destabilization 5

Psychosocial Interventions

• Adjunctive to pharmacotherapy 7
• Focus on lifestyle approaches including nutrition, exercise, sleep hygiene, and weight management 8

Common Pitfalls in Management

• Misdiagnosis, particularly in adolescents with psychotic features 1
• Delayed diagnosis and treatment, worsening prognosis 4
• Poor medication adherence (>50% of patients) 4
• Inappropriate antidepressant monotherapy 5
• Failure to monitor for medical complications of pharmacotherapy 8
• Inadequate attention to comorbid conditions (metabolic syndrome, obesity, smoking, type 2 diabetes) 4

Bipolar disorder requires ongoing monitoring for suicidal ideation, substance use disorders, treatment adherence, and recognition of episode relapse, as mood symptoms, psychosocial functioning, and suicide risk can fluctuate significantly throughout the course of illness 7.