Bipolar disorder

Epidemiology

Basically a milder form of bipolar disorder

Symptoms are not severe enough to diagnose bipolar disorder, with
- Hypomania: not enough for mania
- Dysthymia: not enough for depression
But symptoms are more persistent than regular bipolar
Symptoms last at least 2 years, are present at least half of the time, and are never absent for more than 2 months at a time.

Mnemonic

DIGFAST for features of mania: Distractibility, Irresponsibility, Grandiosity, Flight of ideas, Activity increase, Sleep deficit, and Talkativeness.
SAGECAPS for features of depression: Sleep (insomnia or hypersomnia), Interest loss (Anhedonia), Guilt (low self-esteem), Energy (low energy or fatigue), Concentration (poor concentration or difficulty making decisions), Appetite (decreased appetite or overeating), Psychomotor agitation or retardation, and Suicidal ideation.
- Imagined a very sad wizard in a fancy hat.

Manic episode	Hypomanic episode
• Symptoms more severe	• Symptoms less severe
• 1 week unless hospitalized	• ≥4 consecutive days
• Marked impairment in social or occupational functioning or hospitalization necessary	• Unequivocal, observable change in functioning from baseline • Symptoms not severe enough to cause marked impairment or necessitate hospitalization
• May have psychotic features; makes episode manic by definition	• No psychotic features

Bipolar I
- Manic episode(s)
- Depressive episodes common but not required for diagnosis
Bipolar II
- Hypomanic episode(s)
- ≥1 major depressive episodes

Pharmacotherapy: Consider continuing the drug(s) that resolved the acute manic or depressive episode.
Commonly used agents
- Lithium (preferred): Individualize the dose according to clinical response and serum levels.
  - Adverse effects
    - Diabetes insipidus
    - Hypothyroidism
    - Tremor
    - Ebstein anomaly (teratogenic)
- Valproic acid, lamotrigine
Refractory or severe bipolar episodes
- Combination therapy with a mood stabilizer (e.g., lithium or valproic acid)
- PLUS atypical antipsychotics (e.g., quetiapine, olanzapine, aripiprazole)
Severe depression or predominantly depressive bipolar II disorder: Antidepressants may be started after initiating mood stabilizers.