What symptoms should be assessed during follow-up visits for bipolar 1 disorder medication management?

Symptom Assessment During Follow-Up Visits for Bipolar 1 Medication Management

During follow-up visits for bipolar 1 disorder medication management, systematically assess both manic and depressive symptoms with particular emphasis on depressive symptoms, which dominate the longitudinal course and account for disproportionately more morbidity than manic symptoms. 1, 2

Core Mood Symptom Assessment

Depressive Symptoms (Priority Assessment)

• Assess depressive symptoms at every visit, as they are present 31.9% of weeks during long-term follow-up—nearly 4 times more frequent than manic symptoms (8.9% of weeks). 2
• Evaluate for psychomotor retardation, hypersomnia, and psychotic features, which characterize bipolar depression more than unipolar depression 1
• Screen for suicidality at every visit, as bipolar disorder carries inherent suicide risk and close supervision of high-risk patients must accompany drug therapy. 1, 3
• Use structured tools like the 9-item Patient Health Questionnaire or Beck Depression Inventory for quantitative tracking 4

Manic/Hypomanic Symptoms

• Assess for euphoria, grandiosity, and irritability with associated racing thoughts and increased psychomotor activity 1
• Evaluate sleep disturbance as a hallmark sign—specifically decreased need for sleep rather than insomnia. 1
• Screen for psychotic symptoms, paranoia, and confusion, which frequently accompany adolescent mania 1
• Monitor for mood lability and mixed features (concurrent manic and depressive symptoms) 1

Subsyndromal Symptoms

• Assess subsyndromal and minor affective symptoms, which are present nearly 3 times more frequently (29.9% of weeks) than full syndromal episodes (11.2% of weeks). 2
• Track hypomanic symptoms that don't meet full criteria, as patients change symptom status an average of 6 times per year 2

Functional Impairment Assessment

• Evaluate global, social, and occupational functioning across multiple settings—not just one context—as true bipolar episodes cause impairment across all domains. 1
• Assess whether symptoms represent a marked departure from baseline functioning or chronic temperamental patterns 1
• Monitor quality of life and psychosocial functioning, which are substantially reduced in bipolar disorder 5

Comorbidity Screening

• Screen for anxiety disorders, substance use disorders, and ADHD at regular intervals, as these are highly prevalent comorbidities. 1, 4
• Assess for substance abuse specifically, as comorbid drug-use disorder predicts greater chronicity during follow-up 2
• Evaluate for medical comorbidities including cardiovascular disease, which accounts for excess mortality in this population 5

Medication Adherence Assessment

• Directly assess medication adherence at every visit through patient self-report, appointment-keeping patterns, and plasma drug levels when indicated. 4
• Involve significant others in adherence monitoring, as patients with bipolar disorder are commonly nonadherent 4
• Monitor for decreased adherence (5% per month) in standard care, which leads to increased mood symptoms 1

Medication Side Effect Monitoring

Metabolic Monitoring (Critical for Atypical Antipsychotics)

• Measure body mass index monthly for 3 months, then quarterly. 1
• Obtain fasting glucose and lipid panel at 3 months, then yearly. 1
• Monitor blood pressure at the same intervals 1
• Assess waist circumference and screen for metabolic syndrome 1, 4

Mood Stabilizer-Specific Monitoring

• For lithium: Check lithium levels, thyroid function tests, renal function (BUN, creatinine), urinalysis, and serum calcium every 3-6 months. 1
• For valproate: Monitor liver function tests, complete blood counts, and valproate levels every 3-6 months. 1
• Educate patients about presenting symptoms of adverse effects, as periodic monitoring doesn't ensure abnormalities will be identified promptly 1

Neurological Side Effects

• Monitor for extrapyramidal side effects including tardive dyskinesia at every visit, even with atypical antipsychotics. 1
• Assess for tremor, unsteadiness, and restlessness 4

Other Common Side Effects

• Screen for sedation, nausea, vomiting, diarrhea, constipation, and weight gain 4
• Monitor for anticholinergic effects 3

Relapse Warning Signs

• Assess for early signs of mood episodes so treatment resumption can be initiated promptly if prophylactic therapy has been discontinued. 1
• Track polarity changes, as patients shift polarity more than 3 times per year on average 2
• Monitor for rapid cycling patterns, which are common in early-onset cases 1

Family and Psychosocial Factors

• Assess family conflict and expressed emotion, as improvements in family conflict are associated with greater improvement in suicidal ideation 1
• Evaluate sleep/circadian rhythm patterns, as these are critical targets for intervention 1
• Monitor stressors and triggers that may precipitate episodes 1

Common Pitfalls to Avoid

• Don't focus exclusively on manic symptoms—depressive symptoms dominate the course and require equal or greater attention. 2
• Don't dismiss subsyndromal symptoms as clinically insignificant—they are present most of the time and predict functional impairment. 2
• Don't rely solely on patient self-report for adherence—use multiple verification methods including significant others and drug levels. 4
• Don't skip metabolic monitoring with atypical antipsychotics—obesity and metabolic syndrome lead to high medical morbidity and mortality. 1, 4