What is the recommended approach for screening and treating bipolar disorder?

Screening for Bipolar Disorder

All psychiatric assessments should include specific screening questions for bipolar disorder, focusing on distinct periods of mood changes with associated sleep disturbances and psychomotor activation. 1, 2

Screening Approach

• Screen for bipolar disorder by asking about distinct, spontaneous periods of mood changes associated with sleep disturbances and psychomotor activation 1
• Assess history of depression and family history of mood disorders, as these are important risk factors 1
• Two simple screening questions about mood and anhedonia ("Over the past 2 weeks, have you felt down, depressed, or hopeless?" and "Over the past 2 weeks, have you felt little interest or pleasure in doing things?") can be effective initial screening tools 1
• The Mood Disorder Questionnaire (MDQ) is the most widely used screening instrument for bipolar disorder in outpatient settings 3
• All positive screening results should trigger full diagnostic interviews using standard DSM criteria 1

Diagnostic Assessment

• Follow DSM criteria, including duration criteria, when making a diagnosis of mania or hypomania 1, 2
• Differentiate manic symptoms from other conditions with similar presentations (ADHD, disruptive behavior disorders, PTSD) 1, 2
• Organize clinical information using a life chart to characterize course of illness, patterns of episodes, severity, and treatment response 1, 2
• Manic grandiosity and irritability present as marked changes in mental and emotional state, rather than reactions to situations or temperamental traits 1
• Bipolar disorder is often misdiagnosed as unipolar depression, with patients consulting 3 or more professionals before receiving a correct diagnosis and an average time to first treatment of 10 years 3

Treatment Approach

• Pharmacotherapy with mood stabilizers and/or atypical antipsychotics is the primary treatment for well-defined bipolar I disorder 4
• For adolescents, start with FDA-approved agents when possible, such as lithium (≥12 years) as monotherapy 4
• Combination therapy with lithium or valproate plus an atypical antipsychotic has shown superior efficacy compared to mood stabilizer monotherapy 4
• Olanzapine is FDA-approved for the treatment of manic or mixed episodes associated with bipolar I disorder in both adults and adolescents (ages 13-17) 5
• Most patients with bipolar I disorder will require ongoing medication therapy to prevent relapse; some individuals will need lifelong treatment 1

Monitoring and Follow-up

• Psychopharmacological interventions require baseline and follow-up symptom, side effect, and laboratory monitoring 1
• For lithium therapy, baseline laboratory assessment should include complete blood cell counts, thyroid function tests, urinalysis, blood urea nitrogen, creatinine, and serum calcium levels 1
• For valproate, baseline liver function tests, complete blood cell counts, and pregnancy tests are recommended 1
• Monitor for metabolic side effects with atypical antipsychotics, including weight gain, diabetes, and hyperlipidemia 1
• Educate patients and families about early signs and symptoms of mood episodes to enable prompt intervention if relapse occurs 1

Special Considerations

• Bipolar disorder is frequently misdiagnosed as major depressive disorder, with approximately 20% of primary care patients with depression actually having bipolar disorder 6
• Antidepressants have demonstrated little efficacy for depressive episodes associated with bipolar disorder and may trigger manic episodes 6, 4
• Life expectancy is reduced by approximately 12-14 years in people with bipolar disorder, with increased cardiovascular mortality occurring 17 years earlier than in the general population 7
• The annual suicide rate is approximately 0.9% among individuals with bipolar disorder, compared with 0.014% in the general population 7
• Medication non-compliance is a major contributor to relapse, with >90% of adolescents who are non-compliant with lithium treatment experiencing relapse 1

Common Pitfalls and Caveats

• Avoid relying solely on checklists to identify psychopathology; assess symptoms in perspective given family, school, peer, and other psychosocial factors 1
• Recognize that bipolar symptoms in children may differ from those in adults and require careful assessment 2
• Be cautious with antidepressant use in bipolar patients as they may trigger manic episodes 4
• Avoid unnecessary polypharmacy while recognizing that multiple agents are often required for symptom control 1
• Ensure accurate diagnosis using DSM criteria before initiating treatment 1, 2