Bipolar disorder is a mood disorder with episodes of mania or hypomania that alternate with periods of depression. Bipolar I needs at least one full manic episode, and long-term mood stabilizers prevent relapses and lower suicide risk.
Key symptoms
- Mania: elevated or irritable mood with high energy for a week or more
- Little need for sleep, racing thoughts, fast pressured speech
- Grandiosity, risky spending, sexual or driving behavior
- Depressive episodes: low mood, loss of interest, fatigue
- Psychosis may appear in severe episodes
What you find on exam
- Mental status exam: pressured speech, flight of ideas, distractibility
- Look for delusions, hallucinations and insight
- Ask about suicidal thoughts and dangerous behavior
- Look for intoxication or a medical cause
Tests
- Diagnosis is clinical, using DSM-5 criteria
- Urine drug screen, thyroid tests, blood count, metabolic panel
- Before lithium: kidney function, thyroid, pregnancy test, ECG if older
- Drug levels for lithium or valproate during treatment
Treatment basics
- Acute mania: an antipsychotic such as olanzapine or quetiapine, or lithium or valproate
- Maintenance with lithium, valproate, lamotrigine or an atypical antipsychotic
- Avoid antidepressants alone; they can trigger mania
- Psychotherapy, sleep routine, family education
- Monitor weight, glucose, lipids and drug side effects
Red flags
- Suicidal thoughts or severe depression
- Mania with psychosis or danger to self or others
- Lithium toxicity: vomiting, tremor, confusion, unsteady gait
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Sources: NCCPA PANCE Content Blueprint; NBOME COMLEX-USA clinical presentations; AAMC Core Entrustable Professional Activities (Core EPAs). Written by Making Synapses. Making Synapses is not affiliated with these organizations.