Bipolar Disorder Diagnosis and Treatment
Diagnostic Criteria
Bipolar disorder diagnosis requires documenting distinct, spontaneous periods of abnormally elevated, expansive, or irritable mood with decreased need for sleep and psychomotor activation, following DSM criteria with specific duration requirements: at least 7 days for mania or 4 days for hypomania. 1
Core Assessment Components
Screen specifically for hallmark manic symptoms: decreased need for sleep (not just insomnia), distinct mood elevation episodes that are clearly different from baseline, and increased goal-directed activity or psychomotor agitation that occurs spontaneously rather than reactively 1
Obtain detailed longitudinal history using a life chart to map when symptom clusters began, their duration, periods of remission, and temporal patterns—this distinguishes episodic bipolar disorder from chronic conditions like DMDD or persistent irritability from other causes 1
Collect collateral information from family members or other sources whenever possible, as patients often lack insight during manic episodes and family can describe behavioral changes and episodic patterns more objectively 1
Document comprehensive psychiatric history including all prior diagnoses (which may have been incorrect), psychiatric hospitalizations, emergency visits for mood issues, and critically—any history of antidepressant-induced mood elevation or agitation, which suggests bipolarity 1
Essential Differential Diagnosis Considerations
Rule out substance-induced mood disorder by obtaining detailed substance use history and toxicology screening to assess temporal relationships between substance use and mood symptoms—this is particularly critical given high rates of comorbid substance use 1
In children and adolescents, differentiate from ADHD, disruptive behavior disorders, and PTSD by focusing on whether symptoms are episodic versus chronic, and whether irritability is reactive to triggers versus spontaneous as part of a mood episode 1
Complete medical evaluation to exclude organic causes including thyroid function tests, complete blood count, and comprehensive metabolic panel 1
Exercise extreme caution in children under age 6, as diagnostic validity has not been established in this population—consider alternative explanations first including developmental disorders, psychosocial stressors, and temperamental difficulties 1
Critical Comorbidity Assessment
Assess suicidality thoroughly at every visit, as bipolar disorder has exceptionally high rates of suicide attempts (annual rate 0.9% versus 0.014% in general population), with 15-20% dying by suicide over their lifetime 1, 2
Screen for substance use disorders, which are particularly prevalent in adolescents and adults with bipolar disorder 1
Evaluate for anxiety disorders, developmental disorders, and cognitive/language impairments, which commonly co-occur and require treatment as part of the comprehensive plan 1
Diagnostic Pitfalls to Avoid
Do not rely solely on irritability as it is non-specific and occurs across multiple diagnoses—focus instead on decreased need for sleep and distinct episodic mood changes 1
Recognize that most patients initially present with depression (approximately 75% of symptomatic time consists of depressive episodes), and diagnosis is often delayed by a mean of 9 years following initial depressive episode 2
Consider bipolar disorder in any patient presenting with depression, especially those with family history of mood disorders, psychotic features, or reverse neurovegetative symptoms 1, 3
Treatment Approach
Initiate treatment with a mood stabilizer (lithium, lamotrigine, or valproate) or quetiapine monotherapy as first-line therapy, and never use antidepressant monotherapy in bipolar disorder due to risk of mood destabilization and manic switching. 4
First-Line Pharmacotherapy Options
Lithium is the gold standard and only FDA-approved agent for bipolar disorder in patients age 12 and older, showing superior evidence for long-term efficacy in preventing both manic and depressive episodes, with specific anti-suicide effects independent of its mood-stabilizing properties 4, 2, 5
Quetiapine (with or without a mood stabilizer) is recommended as first-line for bipolar depression and has strong evidence for efficacy in depressive episodes 4
Lamotrigine is particularly effective for maintenance therapy and preventing depressive episodes, making it an excellent choice when depressive episodes predominate—it is suitable for maintenance in bipolar I disorder 6
Valproate is an effective mood stabilizer for acute mania and maintenance treatment 4, 2
Atypical antipsychotics including aripiprazole, asenapine, lurasidone, and cariprazine are recommended first-line options, though clinicians must monitor for weight gain and metabolic complications 2, 5
Olanzapine is FDA-approved for acute manic or mixed episodes in adults and adolescents (ages 13-17), both as monotherapy (5-20 mg/day) and as adjunct to lithium or valproate, with established efficacy in 3-6 week trials 7
Treatment of Specific Episode Types
For acute mania in adults: Start olanzapine 10-15 mg once daily orally, or lithium/valproate at therapeutic levels 1, 7
For acute mania in adolescents (13-17 years): Start olanzapine 2.5-5 mg once daily with target dose of 10 mg/day, though consider other drugs first given increased potential for weight gain and dyslipidemia in adolescents 7
For bipolar depression: Use lamotrigine, quetiapine, or combination of mood stabilizer with antidepressant—never antidepressant alone 4, 6
For acute agitation with mania or schizophrenia: Olanzapine IM 10 mg (or 5-7.5 mg when clinically warranted), assessing for orthostatic hypotension before subsequent dosing, maximum 3 doses 2-4 hours apart 7
Critical Treatment Principles
When using antidepressants in moderate to severe bipolar depression, always combine with a mood stabilizer to prevent switching to mania—antidepressant monotherapy is contraindicated 4, 6, 8
Continue maintenance treatment for at least 2 years after the last episode given the chronic recurrent nature of the illness 6
Monitor treatment adherence closely, as more than 50% of patients with bipolar disorder are non-adherent to treatment 2
Schedule regular follow-up visits to observe symptom evolution, reassess diagnosis periodically as the clinical picture may evolve, and monitor for suicidal ideation 1
Treatment-Resistant Cases
- Consider ECT for severely impaired patients when medications are ineffective or cannot be tolerated—ECT has shown a 50% reduction in suicide risk in the first year after discharge and may have protective effects particularly in patients with severe depression and psychotic features 4
Special Populations
In adolescents: The increased potential for weight gain and dyslipidemia compared with adults may lead clinicians to consider prescribing other drugs before olanzapine, though it remains FDA-approved and effective 7
In patients with predisposition to hypotensive reactions or slowed metabolism: Use lower starting doses of medications 7
Lifestyle and Monitoring
Conduct annual physical health reviews including monitoring for weight gain, lipid levels, plasma glucose, smoking status, alcohol use, and blood pressure—prevalence rates of metabolic syndrome (37%), obesity (21%), and type 2 diabetes (14%) are substantially higher in bipolar disorder 2, 9
Avoid alcohol and sedatives, which are significantly associated with suicide risk and can worsen mood symptoms 4
Implement active lifestyle approaches including good nutrition, exercise, sleep hygiene, and proper weight management 8
Consider adjunctive psychotherapy as a useful complement to pharmacotherapy for improving longer-term outcomes 3, 8