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  • Bipolar Disorder

Causes

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Bipolar DisorderAka: Mania, Manic Depression

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  1. Epidemiology
    1. Bipolar Incidence: 1% of adults (United States)
    2. Gender predisposition: Men and women equally affected
    3. Age of onset: Early adulthood to mid-40s
    4. Affective disorder Family History confers risk
      1. One parent with affective disorder: 27%
      2. Two parents with affective disorder: 50-75%
  2. Pathophysiology
    1. Related to noradrenergic system (Norepinephrine)
  3. Types
    1. Bipolar I Disorder
    2. Bipolar II Disorder
      1. Recurrent major depressive episodes
      2. Hypomanic episodes
    3. Cyclothymic Disorder (Cyclothymia)
      1. Mild, chronic form of bipolar disorder
  4. Differential Diagnosis
    1. See Mania Secondary Causes
    2. Personality Disorder
    3. Recurrent Major Depression
    4. Schizophrenia
    5. Obsessive-Compulsive Disorder
  5. Diagnosis
    1. See Mania Diagnosis
  6. Labs (consider)
    1. Complete Blood Count
    2. Renal Function tests
    3. Chemistry panel
    4. Thyroid Function Tests
    5. Liver Function Tests
    6. Erythrocyte Sedimentation Rate
    7. Syphilis Serology (e.g. RPR)
    8. HIV Test
    9. Serum and Urine drug screen
  7. Diagnostic Testing (consider)
    1. Head CT or MRI
    2. Electroencephalogram (EEG)
  8. Management: Mood Stabilizer Selection
    1. Mood Stabilizers in general
      1. Lithium is preferred over Valproate
        1. Suicide 3x less likely with Lithium than Valproate
      2. Valproate
      3. Carbamazepine
        1. Now available as long acting agent (Equetro)
        2. Therapeutic range for biopolar: 4-12 mcg/ml
    2. Classic mania or hypomania (Euphoric mood)
      1. Lithium (preferred) or
      2. Valproate
    3. Mixed episode or dysphoric mood
      1. Lithium (preferred) or
      2. Valproate or
      3. Carbamazepine
    4. Mania with rapid cycling
      1. Valproate or
      2. Carbamazepine
    5. Alternatives mood stabilizers
      1. Lamotrigine
        1. Consider instead of Lithium
        2. Effective as mood stabilizer and Antidepressant
        3. No blood monitoring needed
        4. Rash develops in 10% of patients
          1. Risk of Steven's Johnson
      2. Oxcarbazepine
        1. Consider instead of Carbamazepine
        2. Similar efficacy with fewer adverse effects
  9. Management
    1. Initial Manic Management
      1. Choose Mood Stabilizer from above
    2. Adjunctive medications: Benzodiazepine
      1. Consider Gabapentin for anxiety
      2. Indications for Benzodiazepine
        1. Mania or hypomania with Insomnia or agitation
        2. Psychosis refractory to Antipsychotic
    3. Adjunctive medications: Antipsychotics
      1. Antipsychotic indications
        1. Psychosis
          1. Consider Electroconvulsive Therapy
        2. Mania with Insomnia or agitation
          1. Despite Benzodiazepine
        3. Acute mania episode
          1. May increase Lithium or Valproate efficacy
      2. Agents (low doses are often effective in mania)
        1. Risperidone (Risperdal) 2-4 mg per day
        2. Olanzapine 10-15 mg per day
        3. Quetiapine 400-800 mg per day
    4. Adjunctive medications: Initial Depression Management
      1. Choose Mood Stabilizer from above
      2. Psychotherapy
      3. Antidepressant (SSRI)
        1. Risk of precipitating mania
        2. Highest risk of mania with tricyclics
      4. Consider Topiramate for depression
    5. Refractory Cases
      1. Consider switching to other mood stabilizer
      2. Consider combining 2-3 mood stabilizers
  10. References
    1. (1997) Am Fam Physician 55(4):1447
    2. Docherty (1996) J Clin Psychiat 57(suppl 12A):1
    3. McIntyre (2004) Can Fam Physician 50:388
    4. Werder (1995) Am Fam Physician 51(5):1126

Manic (C0338831)

Definition (NCI)Excitement of psychotic proportions manifested by mental and physical hyperactivity, disorganisation of behaviour and elevation of mood.
ConceptsMental or Behavioral Dysfunction (T048)
MSHD001714
EnglishMania, Manias, Manic, Manic State, Manic States
Spanishmania, maniaco
Parent ConceptsMental disorders (C0004936), Mood Disorders (C0525045)
SourcesDXP, MSH, MTH, NCI, SCTSPA, SNOMEDCT
Derived from the NIH UMLS (Unified Medical Language System)


Other and unspecified bipolar disorders (C1456309)

ConceptsMental or Behavioral Dysfunction (T048)
ICD9296.8
EnglishOther and unspecified bipolar disorders
Parent ConceptsUnspecified episodic mood disorder (C1456434)
SourcesICD9CM
Derived from the NIH UMLS (Unified Medical Language System)



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