Bipolar Disorder
Bipolar disorder is also known as bipolar affective disorder (term used in the UKMLA content map) or manic depressive disorder.
General Psychiatry Article Disclaimer
- DSM-5 criteria or ICD-11 diagnostic requirements are used to structure the Clinical Features and Diagnosis section. The classification system used is selected according to its clarity and suitability for non-specialist learning.
- The criteria are summarised and simplified rather than reproduced in full, while preserving their original diagnostic meaning.
- Where appropriate, a student-friendly pattern-recognition summary is provided to highlight the most clinically and exam-relevant features.
Exam tip (re-psychiatry questions)
- Do not attempt to memorise every DSM-5 or ICD-11 criterion word-for-word. However, it is important to read through the criteria and become familiar with the key symptom clusters, duration thresholds, exclusions, and distinguishing features highlighted in this article.
- Exam questions may not provide every feature required to meet the full diagnostic criteria. Familiarity with the criteria can help one recognise the most likely diagnosis, exclude important alternatives, and narrow the differential diagnosis.
Epidemiology
Bipolar disorder affects males and females equally
Bipolar disorder is more common in younger age groups
- 3.4% in 16-24 y/o
- 0.4% in 65-74 y/o
Causes and Risk Factors
Bipolar disorder is highly heritable (one of the most heritable psychiatric disorders)
- Bipolar disorder is ~70% heritable
- A first-degree relative of a patient with bipolar disorder has a 5x lifetime risk of developing bipolar disorder
Environmental factors / triggers:
- In utero exposure to Toxoplasma gondii, herpes simplex, or CMV
- Adverse childhood experiences (e.g. maternal death before the child reaches 5 y/o, trauma, abuse, emotional neglect / abuse)
- Cannabis or cocaine use
- Recent childbirth (postpartum psychosis may be the first presentation of bipolar disorder)
Associated Conditions / Comorbidities
Bipolar disorder is associated with:
- Mental health disorders
- Alcohol and other substance misuse disorder
- Anxiety disorder
- Personality disorder
- ADHD
- Cardiovascular disease, hypertension
- Metabolic syndrome, obesity, T2DM, dyslipidaemia
- CKD
- Respiratory disease (e.g. COPD)
21%-58% of women with postnatal depression have bipolar disorder.
Clinical Features and Diagnosis
High-yield pattern recognition for bipolar disorder:
Bipolar disorder is characterised by episodic 1) depressive episode and/or 2) hypomanic or manic episodes
- Manic episode: abnormally elevated mood lasting at least 1 week PLUS severe enough to cause functional impairment OR accompanied by psychotic features (e.g. delusions, hallucinations)
- Other common associated features (e.g. reduced need for sleep, pressured speech, increased talkativeness, flights of ideas, increased goal-directed activity, uncontrolled spending, reckless investments, sexual indiscretions)
- Hypomanic episode: similar to manic episode but symptoms lasting at least 4 days PLUS no functional impairment PLUS no psychotic features
- Depressive episode: at least 2 weeks of depression
The DSM-5 criteria splits bipolar disorder into 2: [Ref]
| Bipolar I disorder | Characterised by at least 1 manic episode
Not better explained by other schizophrenia-spectrum or psychotic disorders (e.g. schizophrenia, schizotypal, schizoaffective, delusional disorder) |
| Bipolar II disorder | Characterised by
Not better explained by other schizophrenia-spectrum or psychotic disorders (e.g. schizophrenia, schizotypal, schizoaffective, delusional disorder) |
DSM-5 criteria of various episodes seen in bipolar disorder: [Ref]
| Episode type | Diagnostic criteria |
|---|---|
| Manic episode | ALL the following must be met:
|
| Hypomanic episode | ALL the following must be met:
|
| Major depressive episode |
Note this is the same as the DSM-5 criteria for depression (i.e. major depressive episode) ALL the following must be met:
|
To diagnose bipolar disorder in children:
- Mania must be present, and
- Euphoria must be present on most days and for most of the time, for at least 7 days, and
- Irritability is NOT a core diagnostic criterion
Depression is NOT required for a diagnosis of bipolar disorder. Most patients with bipolar disorder present initially with a depressive episode, and some with a diagnosis of unipolar depression will actually have bipolar disorder.
Therefore, when a patient presents with depressive symptoms, always assess for any previous or concurrent features of mania or hypomania (e.g. by asking for periods of overactivity or disinhibited behaviour).
Cyclothymic disorder is characterised by chronic fluctuations between hypomanic and depressive symptoms that do not meet the full criteria for hypomanic or major depressive episodes, persisting for ≥2 years in adults.
Complications
Bipolar disorder has the highest lifetime risk of suicide among all psychiatric conditions [Ref]
Other complications from disinhibition and impaired social functioning:
- Overspending → financial difficulties
- Injuries and accidents
- STIs and unplanned pregnancy
- Damage to reputation, occupation, and relationships
- Self-neglect, exhaustion, and dehydration
- Exploitation by others
- Alcohol and substance misuse
- Gambling-related harms
- Reduced quality of life and functioning
- Harm to others from:
- Neglect
- Depressive or paranoid delusions
- Grandiosity, overspending, poor judgement, and erratic or chaotic behaviour (e.g. resulting in road traffic accidents)
- Rarely, violence and aggression (particularly if there is a personal history of violent behaviour)
Management
Management approach / referral:
- Refer urgently to specialist mental health assessment if ANY of the following
- Mania
- Severe depression (i.e. symptoms are markedly interfering with functioning)
- Patient poses a danger to themselves or others
- Consider referring hypomania to specialist mental health assessment
- If bipolar is suspected in children (<14 y/o) → refer to Child and Adolescent Mental Health Services (CAMHS)
Do NOT start the following medications in primary care to manage bipolar disorders:
- Lithium (in those who have not taken lithium before, except under shared-care arrangements)
- Sodium valproate
- Antipsychotics
Acute Management
Mania / Hypomania
Mania / hypomania should NOT be managed solely in primary care.
Step up accordingly if ineffective:
- Step 1: offer an antipsychotic (haloperidol / olanzapine / quetiapine / risperidone), and stop any antidepressants (if patient is taking one)
- Step-up accordingly if there is inadequate response:
- Step 2: offer an alternative antipsychotic
- Step 3: add lithium
- Step 4: add sodium valproate
- Last resort: ECT for rapid short-term treatment of prolonged or severe manic episode
If the patient is already on mood stabilisers (e.g. lithium, sodium valproate):
- 1st line: optimise medication dose
- If that fails, then add drugs as outlined above
NB if taking lithium, measure plasma lithium levels to guide treatment optimisation based on lithium targets
Bipolar Depression
Offer all patients psychological intervention
Pharmacological interventions are indicated if there is moderate / severe bipolar depression:
- 1st line: olanzapine PLUS fluoxetine OR quetiapine monotherapy
- If the patient prefers: olanzapine or lamotrigine monotherapy can be considered
- If ineffective: lamotrigine monotherapy
If the patient is already on mood stabilisers (e.g. lithium, sodium valproate):
- 1st line: optimise medication dose
- If that fails, then add drugs as outlined above
NB if taking lithium, measure plasma lithium levels to guide dose optimisation based on lithium targets
The core concept of treating bipolar depression is NOT to offer an antidepressant alone. Either give an antidepressant with an antipsychotic, or don’t at all.
Long-Term Management (Preventive Treatment)
Conservative / general management:
- Offer psychological interventions and family intervention
- Develop a collaborative care plan and a risk management (crisis) plan with the patient
Choice of pharmacological treatment (i.e. mood stabilisers):
- 1st line: lithium monotherapy
- 2nd line: antipsychotic monotherapy (e.g. risperidone, quetiapine, olanzapine, aripiprazole, asenapine)
- 3rd line (combination therapy): sodium valproate PLUS lithium OR antipsychotic
If the patient’s symptoms respond effectively to treatment and they remain stable, they should be offered the option to return to primary care
Due to the risk of fetal malformations and neurodevelopmental outcomes, strict MHRA safety advice must be followed when using valproate, especially for women and girls of childbearing potential, and for people (male or female) younger than 55 y/o.
References