From the Guidelines
Bipolar disorder diagnosis requires a comprehensive psychiatric evaluation assessing mood patterns, behavior, and symptoms over time, with a focus on identifying at least one manic or hypomanic episode, as outlined in the DSM-IV-TR criteria 1.
Key Diagnostic Criteria
- Bipolar I disorder: at least one manic episode lasting 7 days or more, unless hospitalization is required 1
- Bipolar II disorder: at least one hypomanic episode lasting 4 days or more and one major depressive episode 1
- Mixed episode: a period of 7 days or more with symptoms of both manic and depressive episodes 1
- Rapid cycling: at least four mood episodes in one year, with each episode meeting the prerequisite duration criteria 1
Assessment and Evaluation
The diagnostic assessment should incorporate both current and past history regarding symptomatic presentation, treatment response, psychomotor, sleep, and cognitive changes, as well as family psychiatric history 1. A life chart can be helpful in characterizing the course of illness, patterns of episodes, severity, and treatment response 1. It is essential to rule out other confounding illnesses and identify comorbid disorders that need to be addressed as part of a comprehensive treatment plan 1.
Treatment and Management
Treatment usually involves mood stabilizers like lithium (600-1200mg daily), valproate (750-1500mg daily), or lamotrigine (100-200mg daily), often combined with atypical antipsychotics such as quetiapine (300-800mg daily) or olanzapine (5-20mg daily) 1. Psychotherapy, particularly cognitive behavioral therapy and interpersonal therapy, is also essential for managing bipolar disorder 1. Early and accurate diagnosis is crucial as untreated bipolar disorder can worsen over time, leading to more severe episodes and increased suicide risk 1.
Special Considerations
In children and adolescents, the diagnosis of bipolar disorder can be challenging due to the presence of manic-like symptoms that may not meet the full criteria for mania or hypomania 1. The diagnostic validity of bipolar disorder in young children has yet to be established, and caution must be taken before applying this diagnosis in preschool children 1. Youths with suspected bipolar disorder must also be carefully evaluated for other associated problems, including suicidality, comorbid disorders, psychosocial stressors, and medical problems 1.
From the Research
Diagnosis of Bipolar Disorder
- Bipolar disorder is characterized by recurrent episodes of depression and mania or hypomania, with bipolar depressive episodes similar to major depressive episodes 2.
- Manic and hypomanic episodes are marked by a distinct change in mood and behavior during discrete time periods, with the age of onset typically between 15 and 25 years 2.
- Depression is the most frequent initial presentation, and approximately 75% of symptomatic time consists of depressive episodes or symptoms 2.
Diagnostic Challenges
- Early diagnosis and treatment are crucial for a more favorable prognosis, but diagnosis and optimal treatment are often delayed by a mean of approximately 9 years following an initial depressive episode 2.
- Misdiagnoses are frequent, potentially resulting in missed early intervention and increasing the risk of iatrogenic harm 3.
- The clinical manifestations of bipolar disorder can be markedly varied between and within individuals across their lifespan, making early diagnosis challenging 3.
Treatment Options
- First-line therapy includes mood stabilizers, such as lithium, anticonvulsants, such as valproate and lamotrigine, and atypical antipsychotic drugs, such as quetiapine, aripiprazole, asenapine, lurasidone, and cariprazine 2, 4.
- Antidepressants are not recommended as monotherapy, and combination therapy and adjunctive psychotherapy may be necessary to treat symptoms across different phases of illness 2, 3, 4.
- Lithium continues to be the most effective drug overall, although full remission is only seen in a subset of patients, and newer atypical antipsychotics are increasingly being found to be effective in the treatment of bipolar depression 3.
Management and Prognosis
- Long-term treatment consists of mood stabilizers, and antipsychotic agents, with ongoing management involving monitoring for suicidal ideation, substance use disorders, treatment adherence, and recognizing medical complications of pharmacotherapy 2, 4.
- Life expectancy is reduced by approximately 12 to 14 years in people with bipolar disorder, with a 1.6-fold to 2-fold increase in cardiovascular mortality occurring a mean of 17 years earlier compared with the general population 2.
- Approximately 15% to 20% of people with bipolar disorder die by suicide, and the annual suicide rate is approximately 0.9% among individuals with bipolar disorder, compared with 0.014% in the general population 2.