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.
Medication-induced mood disorder
- High-Yield Offending Medications:
- Glucocorticoids (most common; triggers mania, hypomania, depression, or psychosis; dose-dependent risk, esp. prednisone >40 mg/day). c
- Interferon-alpha (high incidence of MDD and suicidal ideation).
- Antiepileptic Drugs (notably Levetiracetam → irritability, aggression, depression).
- Isotretinoin (depression, suicidal ideation).
- Varenicline (neuropsychiatric changes, depressed mood, SI).
- Efavirenz (NNRTI → vivid dreams, insomnia, severe depression, psychosis).
- Antihypertensives (historically Reserpine, Methyldopa, Propranolol/Beta-blockers).
- Antidepressant monotherapy in unrecognized Bipolar Disorder (triggers rapid switch to mania/hypomania).
- Substances of Abuse:
- Intoxication: Cocaine/amphetamines (mania), EtOH/sedatives (depression).
- Withdrawal: Stimulants (“crash” depression), EtOH/opioids/benzos (dysphoria, anxiety).
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 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
- Cyclothymic disorder
- ≥2 years of fluctuating, mild hypomanic & depressive symptoms that do not meet criteria for hypomanic or major depressive episodes
Treatment
- Acute Mania:
- First-line: Antipsychotics (e.g., olanzapine, risperidone) or Mood Stabilizers (Lithium, Valproate). c
- Severe mania: Combination therapy (Antipsychotic + Lithium/Valproate). Add short-acting Benzodiazepine (e.g., Lorazepam) for acute agitation/insomnia. c
- Maintenance:
- First-line: Lithium, Valproate, Quetiapine, Lamotrigine. c2
- Bipolar Depression:
- Lamotrigine, Lurasidone, Quetiapine.
- CONTRAINDICATION: Antidepressant monotherapy (SSRIs/TCAs) → risk of precipitating mania. Must use with mood stabilizer. c2
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.