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

Diagnostic Criteria and Treatment Options for Bipolar Disorder

The diagnosis of bipolar disorder requires careful assessment for distinct periods of abnormally elevated, expansive, or irritable mood that represent a marked departure from baseline functioning, along with treatment that typically includes mood stabilizers and/or atypical antipsychotics as first-line pharmacotherapy. 1

Diagnostic Criteria

Core Features

• Psychiatric assessments should include specific screening questions for bipolar disorder, focusing on distinct, spontaneous periods of mood changes with associated sleep disturbances and psychomotor activation 1
• DSM-IV-TR criteria, including duration criteria, must be followed when diagnosing mania or hypomania 1
• Manic episodes are characterized by abnormally and persistently elevated, expansive, or irritable mood that represents a departure from baseline functioning 1
• Key symptoms include decreased need for sleep (not just insomnia), affective lability, and cognitive changes 1

Bipolar Disorder Types

• Bipolar I Disorder: Requires at least one manic episode (lasting ≥7 days or requiring hospitalization) 1, 2
• Bipolar II Disorder: Characterized by hypomanic episodes (lasting ≥4 days) and depressive episodes without full mania 3
• Bipolar Disorder NOS: Used for youths with manic symptoms lasting hours to less than 4 days or those with chronic manic-like symptoms representing their baseline functioning 4

Differential Diagnosis

• Manic symptoms must be differentiated from symptoms of other common disorders such as ADHD, disruptive behavior disorders, and PTSD 1, 2
• Manic grandiosity and irritability present as marked changes in the individual's mental state, rather than reactions to situations or temperamental traits 2
• Evaluate for substance abuse which may simulate mood changes in bipolar disorder 5

Special Considerations by Age Group

Adolescents

• Acute psychosis may be the first presentation of mania in adolescents 2
• Adolescents with bipolar disorder have high rates of suicide attempts and completed suicides 4
• Substance abuse rates are high in adolescents with bipolar disorder 4, 2

Children and Young Children

• The diagnostic validity of bipolar disorder in preschoolers has not been established 4
• Use extreme caution before applying this diagnosis in children younger than 6 years 2
• For preschool children with mood and behavioral concerns, carefully assess for developmental disorders, psychosocial stressors, parent-child relationship conflicts, and temperamental difficulties 4, 2

Treatment Options

Pharmacotherapy

First-Line Medications

• Treatment should begin with an agent that is FDA-approved for bipolar disorder in adults 4:
  • Lithium: Approved down to age 12 years for acute mania and maintenance therapy 4
  • Atypical antipsychotics: Aripiprazole, valproate, olanzapine, risperidone, quetiapine, and ziprasidone are approved for acute mania in adults 4
  • Maintenance therapy: Both lamotrigine and olanzapine are approved for maintenance therapy in adults 4

Medication Selection Considerations

• Choice of medication should be based on: evidence of efficacy, phase of illness, presence of confounding presentations, side effect profile and safety, patient's history of medication response, and preferences of the patient and family 4
• A history of treatment response in parents may predict response in offspring 4
• Avoid unnecessary polypharmacy, although multiple agents are often required 4

Special Considerations

• Antidepressants may destabilize mood or incite a manic episode and should not be used as monotherapy 4, 5
• Benzodiazepines may be used for acute agitation and sleep disturbance but may cause disinhibition in younger children 4
• Clozapine should be reserved for treatment-refractory cases due to its side-effect profile 4

Adolescent-Specific Treatment

• For adolescents with bipolar I disorder (manic or mixed episodes), olanzapine has shown efficacy in clinical trials 6
• Starting doses should be lower in adolescents: 2.5-5 mg once daily with a target of 10 mg/day 6
• Consider the increased potential for weight gain and dyslipidemia in adolescents when prescribing atypical antipsychotics 6

Psychosocial Interventions

• A multimodal treatment approach combining psychopharmacology with adjunctive psychosocial therapies is indicated 3
• Psychoeducational therapy should provide information about symptoms, course, treatment options, impact on functioning, and heritability 3
• Relapse prevention education should focus on medication compliance, recognition of emergent symptoms, and factors that precipitate relapse 3
• Family-focused therapy and interpersonal/social rhythm therapy have shown benefit 3

Monitoring and Follow-up

• Organize clinical information using a life chart to characterize course of illness, patterns of episodes, severity, and treatment response 1, 2
• Continually reevaluate mood symptoms, psychosocial functioning, and suicide risk 7
• Monitor for common medical comorbidities, as life expectancy is reduced by approximately 12-14 years in people with bipolar disorder 8
• Pay attention to metabolic syndrome, obesity, cigarette smoking, and type 2 diabetes, which occur at higher rates in bipolar disorder 8

Common Pitfalls to Avoid

• Mistaking common behaviors in disruptive children (excessive silliness, grandiose statements) as true manic symptoms 2
• Failing to distinguish between chronic irritability and episodic mood changes 2
• Diagnosing very young children (under age 6) with bipolar disorder without sufficient evidence 2
• Overlooking comorbid conditions that require treatment as part of a comprehensive plan 2
• Delaying diagnosis and treatment, which can worsen prognosis (diagnosis is often delayed by approximately 9 years following an initial depressive episode) 8