Bipolar disorder Study Guide

📖 Core Concepts Bipolar disorder – a mood‐regulating illness with alternating depressive and elevated‑mood (mania/hypomania) episodes. Mania – ≥1 week of abnormally elevated mood, increased energy, ↓need for sleep, risky behavior; may include psychosis. Hypomania – ≥4 days of similar symptoms without marked functional impairment. Rapid cycling – ≥4 mood episodes (mania, hypomania, depression, or mixed) in 12 months. Mixed episode – simultaneous manic (e.g., grandiosity) and depressive (e.g., guilt, suicidality) features. Prodrome – early, sub‑threshold changes (e.g., reduced sleep, irritability) that often precede full episodes. Lithium therapeutic window – serum 0.6–1.2 mEq/L; neuroprotective & suicide‑reducing. --- 📌 Must Remember Prevalence: 2 % (Bipolar I + II); up to 6 % when the broader spectrum is counted. Age of onset: most common 18–25 y (Bipolar I ≈ 18 y, Bipolar II ≈ 22 y). Suicide risk: 15–20 % lifetime death; 30–60 % attempt rate; lithium markedly lowers this risk. Heritability: 0.71–0.93; first‑degree relatives ≈10‑fold risk. Diagnostic thresholds: Mania ≥1 wk, Hypomania ≥4 days; DSM‑5 requires ≥1 manic episode for Bipolar I, ≥1 hypomanic + ≥1 major depressive episode for Bipolar II. First‑line acute mania: Lithium or an atypical antipsychotic (e.g., haloperidol, olanzapine, risperidone). First‑line bipolar depression: Lithium + valproate or lurasidone + lithium/valproate (CANMAT/ISBD). Antidepressant caution: Monotherapy not recommended; can trigger mania or rapid cycling. Rapid‑cycling trigger: Antidepressants, sleep deprivation, substance use. Key labs: Lithium level (0.6–1.2 mEq/L), renal & thyroid function; Valproate level (50–125 µg/mL). --- 🔄 Key Processes Diagnosing a Bipolar Episode Assess mood duration (mania ≥7 days, hypomania ≥4 days). Count symptoms: ≥3 (≥4 if mood is irritable only) for mania; ≥5 for major depression. Determine episode polarity & presence of psychosis. Managing Acute Mania Stabilize safety → possible hospitalization. Initiate lithium or rapid‑acting atypical antipsychotic. Add benzodiazepine for agitation (short‑term). Transition to maintenance (see below). Maintenance / Relapse Prevention Continue mood stabilizer at therapeutic level. Psychoeducation + regular sleep‑wake schedule (IPSRT). Monitor labs every 3–6 mo (renal, thyroid, liver, electrolytes). Treating Rapid Cycling Avoid antidepressants. Use combination of lithium + atypical antipsychotic or valproate. Consider adjunctive lamotrigine for depressive poles. --- 🔍 Key Comparisons Mania vs. Hypomania Duration: ≥1 wk vs. ≥4 days. Impairment: Marked functional decline vs. minimal/none. Hospitalization: Often needed for mania, rarely for hypomania. Lithium vs. Valproate Efficacy: Lithium best for suicide prevention & long‑term stability; Valproate superior for acute mania & mixed episodes. Side‑effects: Lithium → thyroid & kidney; Valproate → hepatotoxicity, teratogenicity. Antidepressant Classes (Switch Risk) Low risk: SSRIs, bupropion. High risk: SNRIs, TCAs, tetracyclics. Atypical Antipsychotics for Bipolar Depression Lurasidone, quetiapine, olanzapine‑fluoxetine, cariprazine, lumateperone = FDA‑approved. Clozapine = reserved for refractory cases. --- ⚠️ Common Misunderstandings “All depressed patients are major depressive disorder.” → Many have underlying bipolar II; look for past hypomania. “Antidepressants cure bipolar depression.” → They must be paired with mood stabilizers; monotherapy can cause switching. “Lithium is outdated.” → Still the gold‑standard for suicide prevention and maintenance. “Rapid cycling is rare.” → Occurs in up to 20 % of patients, especially with antidepressant exposure. --- 🧠 Mental Models / Intuition “Mood polarity wheel” – picture mood states around a clock: mania at 12 o’clock (high energy), depression at 6 o’clock (low energy). Rapid cycling = the wheel spins fast. “Switch trigger thermometer” – each sleep loss, stimulant, or antidepressant exposure raises the “switch risk” temperature; > 37 °C = high chance of manic switch. --- 🚩 Exceptions & Edge Cases Mixed episodes can meet criteria for both mania and depression; treat as mania (antipsychotic + mood stabilizer). Bipolar in the elderly: milder mania, prominent cognitive deficits; use lower drug doses, watch for side‑effects. Pregnancy: Lithium, valproate, carbamazepine are teratogenic; weigh relapse risk vs. fetal risk, consider haloperidol or ECT for severe episodes. Cyclothymia: chronic sub‑threshold swings ≥2 years (adults) → treat with psychoeducation and mood stabilizer if impairment present. --- 📍 When to Use Which Acute Mania → Lithium or atypical antipsychotic (haloperidol, olanzapine, risperidone). Add benzodiazepine for agitation. Acute Bipolar Depression → Lurasidone + lithium/valproate or quetiapine; consider lamotrigine for maintenance. Rapid Cycling → Avoid antidepressants; use combination lithium + atypical antipsychotic or valproate. Pregnant patient → Prefer haloperidol or ECT; if mood stabilizer needed, use lowest effective lithium dose with close monitoring. Pediatric patient → Lithium (only FDA‑approved), plus psychotherapy; avoid valproate unless benefits outweigh teratogenic risk. --- 👀 Patterns to Recognize Sleep ↓ + Goal‑directed activity ↑ → impending manic episode. Psychomotor slowing + anhedonia + guilt → depressive episode. Abrupt mood swing + psychosis → mixed episode (high suicide risk). History of antidepressant use + new manic symptoms → medication‑induced switch. --- 🗂️ Exam Traps “Manic episode must last 2 weeks.” – Wrong; DSM‑5 requires ≥1 week. “Antidepressants are first‑line for bipolar depression.” – Misleading; they are adjunctive only with mood stabilizer, and many increase switch risk. “Lithium is contraindicated in all women of childbearing age.” – Over‑generalized; risk‑benefit analysis required; alternatives also have teratogenic potential. “Rapid cycling is defined by 4 manic episodes only.” – Incorrect; any combination of manic, hypomanic, depressive, or mixed episodes counts. “Atypical antipsychotics are ineffective for mania.” – False; they are superior to lithium/anticonvulsants for acute mania in many trials. ---