Bipolar

General Overview

• Mania
  • Distinct period of abnormally persistently elevated, expansive or irritable mood and goal-directed activity/energy >1w (or hospitalization) most of the day nearly every day
  • ≥3 (or 4 if mood only irritable)
    • Grandiosity (inflated self esteem)
    • Sleep (decreased need, eg. rested after 3h of sleep)
    • Talkative
    • Pleasurable activities that have high potential for Painful consequences
    • Activity (goal-directed) or psychomotor Agitation
    • Ideas (flight of)
    • Distractibility
  • Impaired function, not attributable to substance or medical condition
• Hypomania
  • Meets criteria but lasts only 4-6 days
  • No marked impairment in function
  • Absent psychotic features (if present, would be manic)
• Bipolar I
  • ≥ one manic or mixed episode
• Bipolar II
  • ≥1 MDE + ≥1 hypomanic episode (>4d, not severe enough to affect function, not need hospitalization, no psychotic features)
• Specifiers: with anxious distress, depressed with mixed features, hypo/manic with mixed features, melancholic features, atypical features, mood-congruent or -incongruent psychotic features, catatonia, peripartum onset, seasonal pattern, rapid cycling (4+ mood episodes in a 1 yr)
• Cyclothymia
  • Numerous hypomanic and depressive symptoms not meeting criteria ≥2 years (never asymptomatic >2mo)
  • Impaired function

DDx

• Anxiety
• Depression
• Personality (Narcissitic, Borderline, Antisocial)
• Substance use disorders
• Medications
• Medical condition (endocrine)

Labs

• CBC, electrolytes (Glucose, Cr), lipids, LFT and Bili, INR, TSH, EKG
• bhCG, prolactin
• Urine analysis
• Urine toxicology
• Monitoring
  • Lithium:
    • Levels weekly until stable then q3-6 months (target 0.6-0.8mmol/L)
    • LFT, electrolytes (Urea, Cr, Calcium), TSH q3-6mo
  • Divalproex: Levels do not need to be monitored
    • LFT, CBC q6mo then yearly