What are the diagnostic criteria and treatment options for bipolar disorder?

Diagnostic Criteria and Treatment Options for Bipolar Disorder

Pharmacotherapy is the primary treatment for bipolar disorder, with lithium, valproate, and atypical antipsychotics as first-line medications, while psychosocial interventions serve as important adjunctive therapies to promote medication adherence and address functional impairments. 1

Diagnostic Criteria

DSM-IV-TR Criteria for Bipolar Disorder

• Manic Episode:

  • Duration of at least 7 days (or any duration if hospitalization is required)
  • Characterized by euphoria, grandiosity, irritability, racing thoughts, decreased need for sleep
  • Represents a significant departure from baseline functioning 2
  • Must cause marked impairment in functioning or require hospitalization

• Hypomanic Episode:

  • Similar symptoms to mania but less severe
  • Duration of at least 4 days
  • Does not cause marked impairment or require hospitalization 2

• Mixed Episode:

  • Lasts ≥7 days with symptoms meeting criteria for both manic and depressive episodes 2

• Bipolar I Disorder:

  • At least one manic episode (with or without history of depression)
  • Diagnosis can be made based on a single manic episode 1, 2

• Bipolar II Disorder:

  • At least one hypomanic episode AND at least one major depressive episode
  • No history of manic episodes 2

• Bipolar Disorder NOS:

  • Used for youths with manic symptoms lasting hours to less than 4 days
  • Or for those with chronic manic-like symptoms representing their baseline functioning 1

Key Diagnostic Considerations

• Screening should include questions about distinct periods of mood changes with sleep disturbances and psychomotor activation 1
• Family history of mood disorders is important to assess
• Symptoms should represent a marked departure from baseline functioning and be evident across different settings 1
• Early-onset cases (before age 13) are predominantly male with common premorbid conditions including disruptive behavior disorders and anxiety 2

Treatment Options

Pharmacotherapy for Acute Mania

1. First-line medications: 1, 2

   • Lithium (FDA approved for ages 12+ for acute mania and maintenance)
   • Valproate
   • Atypical antipsychotics (aripiprazole, olanzapine, risperidone, quetiapine, ziprasidone)

2. Medication selection factors: 1

   • Evidence of efficacy
   • Phase of illness
   • Presence of confounding presentations (e.g., rapid cycling, psychotic symptoms)
   • Side effect profile and safety
   • Patient's history of medication response
   • Patient/family preferences

3. Olanzapine specifics: 3

   • Effective as monotherapy for acute manic or mixed episodes
   • Also effective as adjunct to lithium or valproate
   • FDA approved for adolescents (ages 13-17) with flexible dosing (2.5-20 mg/day)
   • Combination of olanzapine and fluoxetine is approved for bipolar depression in adults

Pharmacotherapy for Bipolar Depression

1. First-line treatments: 4, 5

   • Mood stabilizers (lithium, lamotrigine)
   • Atypical antipsychotics (quetiapine, lurasidone)
   • Olanzapine-fluoxetine combination (first treatment specifically approved for bipolar depression)

2. Important considerations:

   • Antidepressant monotherapy is contraindicated in bipolar I depression 4
   • Antidepressants should only be used with a mood stabilizer to prevent treatment-emergent affective switches 4, 6
   • Bupropion or SSRIs are preferred when antidepressants are needed 4

Maintenance Treatment

1. Duration considerations:

   • Most patients require ongoing medication therapy to prevent relapse 1
   • Some individuals need lifelong treatment 1

   • 80% of patients with a manic episode will have at least one relapse 1

   • 90% of adolescents who are non-compliant with lithium treatment relapse 1

2. Monitoring requirements: 1

   • Lithium: baseline complete blood count, thyroid function, urinalysis, BUN, creatinine, calcium; monitor every 3-6 months
   • Valproate: baseline liver function, complete blood count, pregnancy test; monitor every 3-6 months
   • Atypical antipsychotics: monitor weight, BMI, blood pressure, fasting glucose, and lipid panel

Adjunctive Treatments

1. Psychosocial interventions: 1

   • Psychoeducational approaches
   • Family therapy
   • Individual interpersonal therapy
   • Social rhythm therapy

2. Electroconvulsive Therapy (ECT): 1

   • For severely impaired adolescents with manic or depressive episodes unresponsive to medications
   • Considered treatment of choice for bipolar disorder during pregnancy, catatonia, or neuroleptic malignant syndrome

Special Considerations

Comorbidities

• ADHD: May require stimulant treatment after mood stabilization 1
• Substance abuse disorders require specific targeted interventions 7

Mortality Risk

• Life expectancy reduced by 12-14 years 5
• 1.6-2 fold increased risk of cardiovascular mortality 5
• Annual suicide rate approximately 0.9% (vs 0.014% in general population) 5

Common Pitfalls to Avoid

• Misdiagnosis is common, particularly in adolescents with psychotic features who may be incorrectly diagnosed with schizophrenia 2
• Diagnosis is often delayed by approximately 9 years following initial episode 2, 5
• Antidepressant monotherapy can trigger manic episodes and worsen the course of illness 4, 6
• Unnecessary polypharmacy should be avoided; discontinue agents that haven't demonstrated significant benefit 1
• Monitor for metabolic side effects of atypical antipsychotics (weight gain, diabetes, hyperlipidemia) 1, 5

By following these evidence-based diagnostic criteria and treatment approaches, clinicians can improve outcomes for patients with bipolar disorder while minimizing risks associated with inappropriate management.