Bipolar I disorder

Risk factors

Currently, there are no single, clear causes of bipolar disorder. However, there are evidence that suggest there may be a genetic component that contribute to the development of bipolar disorder. Studies from identical twins suggest that there is a 5-10% lifetime risk (about seven times greater compared to the general population) of developing bipolar disorder if there is a first-degree relative diagnosed with bipolar disorder. Bipolar disorder appears to be more common in high-income countries compared to low-income countries, and higher rates of bipolar I disorder are seen in individuals that are separated, divorced, or widowed compared to those who are married or never married.

Diagnosis

The essential feature of bipolar I disorder is a clinical course characterized by the occurrence of one or more manic episodes or mixed episodes. One episode of mania is sufficient to make the diagnosis of bipolar disorder. Often, individuals have had one or more major depressive episodes and may or may not have a history of major depressive disorder. Because depression is typically one of the first symptoms of bipolar disorders, the initial diagnosis of bipolar disorder may be delayed.

Episodes of substance-induced mood disorder due to the direct effects of a medication, or other somatic treatments for depression, substance use disorder, or toxin exposure, or of mood disorder due to a general medical condition need to be excluded before a diagnosis of bipolar I disorder can be made. Bipolar I disorder requires confirmation of only 1 full manic episode for diagnosis, but may be associated with hypomanic and depressive episodes as well. In contrast, diagnosis for bipolar II disorder does not include a full manic episode; instead, it requires the occurrence of both a hypomanic episode and a major depressive episode. Serious aggression has been reported to occur in one out of every ten major, first-episode, BD-I patients with psychotic features, the prevalence in this group being particularly high in association with a recent suicide attempt, alcohol use disorder, learning disability, or manic polarity in the first episode.

Bipolar I disorder often coexists with other disorders including PTSD, substance use disorders, and a variety of mood disorders. Studies suggest that psychiatric comorbidities correlate with further impairment of day-to-day life. Up to 40% of people with bipolar disorder also present with PTSD, with higher rates occurring in women and individuals with bipolar I disorder. A diagnosis of bipolar 1 disorder is only given if bipolar episodes are not better accounted for by schizoaffective disorder or superimposed on schizophrenia, schizophreniform disorder, delusional disorder, or a psychotic disorder not otherwise specified.

Medical assessment

Regular medical assessments are performed to rule-out secondary causes of mania and depression. These tests include complete blood count, glucose, serum chemistry/electrolyte panel, thyroid function test, liver function test, renal function test, urinalysis, vitamin B₁₂ and folate levels, HIV screening, syphilis screening, and pregnancy test, and when clinically indicated, an electrocardiogram (ECG), an electroencephalogram (EEG), a computed tomography (CT scan), or a magnetic resonance imagining (MRI) may be ordered. Drug screening includes recreational drugs, particularly synthetic cannabinoids, and exposure to toxins.

Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV-TR)

Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5)

In May 2013, American Psychiatric Association released the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). There are several proposed revisions to occur in the diagnostic criteria of Bipolar I Disorder and its subtypes. For Bipolar I Disorder 296.40 (most recent episode hypomanic) and 296.4x (most recent episode manic), the proposed revision includes the following specifiers: with psychotic features, with mixed features, with catatonic features, with rapid cycling, with anxiety (mild to severe), with suicide risk severity, with seasonal pattern, and with postpartum onset. Bipolar I Disorder 296.5x (most recent episode depressed) will include all of the above specifiers plus the following: with melancholic features and with atypical features. The categories for specifiers will be removed in DSM-5 and criterion A will add or there are at least 3 symptoms of major depression of which one of the symptoms is depressed mood or anhedonia. For Bipolar I Disorder 296.7 (most recent episode unspecified), the listed specifiers will be removed.

The criteria for manic and hypomanic episodes in criteria A & B will be edited. Criterion A will include "and present most of the day, nearly every day", and criterion B will include "and represent a noticeable change from usual behavior". These criteria as defined in the DSM-IV-TR have created confusion for clinicians and need to be more clearly defined.

There have also been proposed revisions to criterion B of the diagnostic criteria for a Hypomanic Episode, which is used to diagnose For Bipolar I Disorder 296.40, Most Recent Episode Hypomanic. Criterion B lists "inflated self-esteem, flight of ideas, distractibility, and decreased need for sleep" as symptoms of a Hypomanic Episode. This has been confusing in the field of child psychiatry because these symptoms closely overlap with symptoms of attention deficit hyperactivity disorder (ADHD).

ICD-10

• F31 Bipolar Affective Disorder
• F31.6 Bipolar Affective Disorder, Current Episode Mixed
• F30 Manic Episode
• F30.0 Hypomania
• F30.1 Mania Without Psychotic Symptoms
• F30.2 Mania With Psychotic Symptoms
• F32 Depressive Episode
• F32.0 Mild Depressive Episode
• F32.1 Moderate Depressive Episode
• F32.2 Severe Depressive Episode Without Psychotic Symptoms
• F32.3 Severe Depressive Episode With Psychotic Symptoms

Differential diagnosis

When evaluating an individual for bipolar I disorder, other psychiatric conditions that mimic or present with similar symptoms to bipolar I disorder must be considered. It is possible that some of these may be co-occurring with bipolar I disorder.

• Other bipolar disorders, such as bipolar II or bipolar disorder due to another medical condition
• Major depressive disorder with hypomanic or manic symptoms
• Anxiety disorders including generalized anxiety disorder (GAD), panic disorder, post-traumatic stress disorder (PTSD)
• Attention deficit hyperactivity disorder (ADHD)
• Substance or medication-induced bipolar disorder
• Personality disorders such as borderline personality disorder

Management

Medication

Pharmacotherapy is the primary method of managing bipolar disorder, with multiple medications and combinations available. Medications used may vary depending on the side effect profile and patient preference as well as the phase of bipolar disorder being managed (acute mania, bipolar depression, mixed states, or maintenance relapse prevention).

1. Lithium (has a narrow therapeutic range and typically requires monitoring). It has suicide-protective effects, with an 87% reduction in suicide risk compared to placebos in mood disorders.
2. Anticonvulsants, such as valproate, carbamazepine, or lamotrigine
3. Atypical antipsychotics, such as quetiapine, risperidone, olanzapine, lurasidone, or aripiprazole
4. Combination therapies such as lithium or valproate with antipsychotics

A review of validated treatment guidelines for bipolar disorder by international bodies was published in 2020.

Usage of antidepressants alone in the treatment of bipolar disorders is not recommended. However, antidepressants may be used to supplement mood stabilizers or second-generation antipsychotics (adjuvant therapy). There has been concerns that usage of antidepressants may cause individuals to switch to mania (sometimes referred to as antidepressant-induced mania). Current studies have not shown clear differences in significant risk of switching to mania between different antidepressants when compared to placebos.

For the treatment of treatment-resistant bipolar depression, the NMDA receptor antagonist ketamine and its S-enantiomer esketamine (Spravato) have emerged as rapid-acting anesthetic/sedative options with less risk of overdose than other anesthetics. They act quickly to block NMDA receptors and treat depression, with effects lasting up to a week.

In severe cases, electroconvulsive therapy (ECT), a type of brain stimulation therapy where seizures are electrically induced in anesthetized patients for therapeutic effect, may be used for bipolar depression

Patients with bipolar disorder may benefit from supplemental psychotherapy (e.g., cognitive behavioral therapy) in reducing recurrences and stabilizing depressive phases. Interventions that target sleep regulation and mood monitoring, as well as efforts to reduce stigma, are beneficial in improving their quality of life.

Patients with bipolar disorder may struggle with non-adherence to pharmacological treatment; long-acting injectable antipsychotics may be beneficial with adherence to some patients.

Prognosis

Bipolar I usually has a poor prognosis, which is associated with substance abuse, psychotic features, depressive symptoms, and inter-episode depression. A manic episode can be so severe that it requires hospitalization. An estimated 63% of all BP-I related mania results in hospitalization. The natural course of BP-I, if left untreated, leads to episodes becoming more frequent or severe over time. The absolute risk of suicide is highest for BP-I than all other mood and mental disorders. Approximately 15–20% of people with bipolar disorder die by suicide, with 30–60% making at least one attempt. The attempts use more lethal means than those among the general population. Individuals with BP-I typically have a shorter life expectancy compared to the general population, with estimates suggesting a reduction of 11 to 20 years. With proper treatment, individuals with BP-I can, however, lead a healthy lifestyle.

Education

Psychosocial interventions can be used for managing acute depressive episodes and for maintenance treatment to aid in relapse prevention. This includes psychoeducation, cognitive behavioral therapy (CBT), family-focused therapy (FFT), interpersonal and social rhythm therapy (IPSRT), and peer support.

Information on the condition, importance of regular sleep patterns, routines and eating habits and the importance of compliance with medication as prescribed. Behavior modification through counseling can have positive influence to help reduce the effects of risky behavior during the manic phase. Additionally, the lifetime prevalence for bipolar I disorder is estimated to be 1%, while bipolar spectrum disorder has been estimated to affect as much as 6% of people.