Harvey's Garden

Bipolar disorder

2 min read

Epidemiology

Etiology

Subtypes and variants

Cyclothymia (Cyclothymic disorder)

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.

Clinical features

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.

Diagnostics

Manic episodeHypomanic 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

Treatment

  • Acute Mania:
    • First-line: Antipsychotics (e.g., olanzapine, risperidone) or Mood Stabilizers (Lithium, Valproate).
    • Severe mania: Combination therapy (Antipsychotic + Lithium/Valproate).
  • Maintenance:
    • First-line: Lithium, Valproate, Quetiapine, Lamotrigine.
  • Bipolar Depression:
    • Lamotrigine, Lurasidone, Quetiapine.
    • CONTRAINDICATION: Antidepressant monotherapy (SSRIs/TCAs) → risk of precipitating mania. Must use with mood stabilizer.

Pharmacology: High-Yield Associations & Side Effects

  • Lithium:
    • Ebstein’s anomaly (teratogenic: atrialization of right ventricle).
    • Nephrogenic Diabetes Insipidus (treat with Amiloride).
    • Hypothyroidism (check TSH).
    • Toxicity (Tremor, ataxia, altered mental status): Precipitated by Thiazides, NSAIDs, ACE Inhibitors (↓ clearance).
  • Valproate:
    • Neural Tube Defects (teratogenic: folate antagonist).
    • Hepatotoxicity, Pancreatitis.
  • Lamotrigine:
    • Stevens-Johnson Syndrome (SJS): Must titrate dose slowly.
  • Carbamazepine:
    • Agranulocytosis, SJS.
    • CYP450 Inducer.

Graph View

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