Bipolar disorder

What is another name for bipolar disorder?

Manic-depressive disorder.

What proportion of patients present before age 25?

~70–75%.

What neurotransmitter systems are implicated in bipolar disorder pathophysiology?

Monoamines (dopamine, serotonin, norepinephrine), shifting to systems neurobiology (altered synaptic/circuit functioning), neuroplasticity, gene expression changes.

How long must manic symptoms last to diagnose mania?

≥1 week (most of the day, nearly every day).

What is DIGFAST?

Distractibility, Indiscretion, Grandiosity, Flight of ideas, Activity increase, Sleep decrease, Talkativeness.

How does hypomania differ from mania?

Duration ≥4 days, not severe enough to cause marked impairment

What is a mixed episode?

Criteria for both mania & depression met for ≥1 week.

How many symptoms and for how long are required for a depressive episode?

≥5 symptoms for ≥2 weeks.

what defines Bipolar I disorder?

≥1 manic episode (± hypomania/depression).

What defines Bipolar II disorder?

≥1 hypomanic + depressive episode, but no manic episode.

What is rapid cycling?

≥4 mood episodes (mania, hypomania, depression) in 12 months.

What baseline labs are recommended before treatment?

CBC, electrolytes, renal/liver function, TSH, fasting glucose/lipids, pregnancy test, toxicology if substance use suspected.

List the 4 main goals of bipolar disorder therapy.

• Control acute symptoms

• Reduce number/severity of episodes

• Restore functioning/cognition

• Suicide prevention

What are key non-drug therapies for bipolar disorder?

Psychoeducation, CBT/family therapy, online tools (CANMAT/ISBD, MoodChart), relapse drills, lifestyle (sleep, exercise), treat comorbidities.

What should be stopped if a patient presents with mania?

Antidepressants and stimulants (including caffeine).

What is first-line treatment for acute mania?

Lithium, valproate, or SGA (often combination if severe).

What adjunct can be used short-term for agitation?

Benzodiazepines.

What is lithium’s evidence level in mania & depression?

Level 1, first-line.

How long does lithium take to work?

Mania: 6–10 days; Depression: >1 month.

Name 2 long-term benefits of lithium.

Neuroprotective, anti-suicidal properties.

Major lithium side effects?

GI upset, fine tremor, polydipsia/polyuria, hypothyroidism, weight gain, skin issues, renal dysfunction.

What is the hallmark toxic effect of lithium?

Severe neurotoxicity (ataxia, confusion, seizures).

What must be monitored with lithium?

Serum levels, renal function, TSH, Na, hydration status.

Key patient education points with lithium?

Take same time daily, avoid abrupt salt/caffeine changes, maintain hydration, avoid NSAIDs, report GI/neurologic changes.

When might valproate be preferred over lithium?

Acute mania (faster onset: ~3 days).

Common side effects of valproate?

GI upset, tremor, sedation, weight gain, hair loss, PCOS, hepatotoxicity, pancreatitis, teratogenicity.

What lab tests before starting valproate

CBC, LFTs, weight, BMI, pregnancy test.

Key patient education for valproate?

Take consistently, report liver/pancreas symptoms, avoid in pregnancy, monitor blood work, report unusual bruising or suicidal thoughts.

Why is carbamazepine not commonly used?

Autoinduction, drug interactions, risk of agranulocytosis, SJS/TEN.

What is a key lab to monitor with carbamazepine?

CBC (risk of aplastic anemia).

First-line SGAs for acute mania?

Quetiapine, asenapine, aripiprazole, paliperidone, risperidone, cariprazine.

Why is antidepressant monotherapy avoided in bipolar depression?

Risk of switching to mania/mixed states.

What is the general principle for maintenance treatment?

Continue the drug effective in acute phase.

What is the relapse risk without maintenance therapy?

~70% within 1 year.

What is the main cause of recurrence?

Nonadherence.

Which drugs should be avoided in pregnancy?

Lithium (1st trimester), valproate, carbamazepine.

Which drug is considered safer in pregnancy compared to others?

Lamotrigine.

In older adults, what dosing adjustments are needed?

Lower doses, slower titration.

What supplements have shown mixed/limited evidence in bipolar disorder?

Omega-3s, inositol (may trigger mania), NAC, folic acid, magnesium.