The document discusses bipolar disorder, including its definition, epidemiology, pathogenesis, clinical presentation, diagnosis, differential diagnosis, and treatment approaches. Bipolar disorder is a mood disorder characterized by episodes of mania and depression. It has a prevalence of 1-3% and typically onsets in the early 20s. Treatment involves pharmacotherapy with mood stabilizers like lithium or anticonvulsants for acute episodes and long term maintenance, as well as psychotherapy.

1. “If your kid needs a role model and you ain't it, you're both fucked.”
― George Carlin
DEFINITION OF BIPOLAR DISORDER
● mood disorder
● episodes of mania, hypomania, and major depression
● Types
○ bipolar I
○ Bipolar II
Bipolar I disorder Bipolar II disorder
Manic episode(s) Yes No
Hypomanic episode(s) Commonly occur, but not required Yes
Major depressive episode(s) Usually occur, but not required Yes
Mixed features May occur May occur
Anxious distress May occur May occur
Rapid cycling May occur May occur
Psychotic features May occur May occur
Catatonia May occur May occur
EPIDEMIOLOGY
● Prevalence 1 to 3%
● mean age of onset 20 years
● M=F
Non nobis solum nati sumus
(​Not for ourselves alone are we born​)
-Dr. Eashan Srivastava

2. “If your kid needs a role model and you ain't it, you're both fucked.”
― George Carlin
PATHOGENESIS
● not known
● Genetics
○ Family history is usually +
○ Monozygotic co-twin risk = 40 -70%
● Inflammation
○ Serum markers of inflammation are increased in bipolar disorder
● Psychosocial factors
○ Advancing paternal age
DEFINITION
DSM-5 diagnostic criteria for manic episode
A.​ For >1 week
B.​>=3 of following
1) Inflated self-esteem or grandiosity.
2) Decreased need for sleep
3) More talkative than usual or pressure to keep talking.
4) Flight of ideas or subjective experience that thoughts are racing.
5) Distractibility
6) Increase in goal-directed activity (either socially, at work or school, or sexually) or
psychomotor agitation (ie, purposeless non-goal-directed activity).
7) Excessive involvement in activities that have a high potential for painful
consequences
C.​ Impairment in social or occupational functioning or to necessitate hospitalization
D.​Not attributable to substance abuse or to another medical condition.
Non nobis solum nati sumus
(​Not for ourselves alone are we born​)
-Dr. Eashan Srivastava

3. “If your kid needs a role model and you ain't it, you're both fucked.”
― George Carlin
DSM-5 diagnostic criteria for bipolar major depression
A.​ >=5 of the following of which either 1) or 2) must be +
Duration for > 2 week
1) Depressed mood most of the day
2) Markedly diminished interest or pleasure in all activities
3) Significant weight loss when not dieting or weight gain
4) Insomnia or hypersomnia
5) Psychomotor agitation or retardation
6) Fatigue or loss of energy
7) Feelings of worthlessness or excessive or inappropriate guilt
8) Diminished ability to think or concentrate
9) Suicidal ideation
B.​ Significant distress or impairment in social, occupational, or other important
areas of functioning.
C.​ Not attributable to the direct physiological effects of a substance or to another
medical condition.
CLINICAL PRESENTATION
● Bipolar disorder can present with
○ Mania
○ hypomania
○ major depression
○ mixed features
● Prodrome
○ Irritability
○ Anxiety
Non nobis solum nati sumus
(​Not for ourselves alone are we born​)
-Dr. Eashan Srivastava

4. “If your kid needs a role model and you ain't it, you're both fucked.”
― George Carlin
○ mood swings
○ Agitation
○ Aggressiveness
○ sleep disturbance
● Mania
○ euphoric, or high mood
○ disinhibition (eg, wearing garish clothes or disrobing in public)
○ disregard for social boundaries
○ pursuit of stimulation and social activities (eg, acting flirtatious, renewing old
friendships, or lengthy telephone calls with strangers)
○ increased energy and activity
○ Impulsivity
○ Flight of ideas
○ poor judgement
○ Exaggerated sense of wellbeing and self-confidence
○ Decreased need for sleep
○ Speech
■ Loud
■ pressured
■ difficult to interrupt
○ psychosocial functioning is impaired
○ duration = weeks to months
● Hypomania
○ similar to those of mania, but less severe
○ Psychosocial functioning is normal
○ generally begins suddenly and progresses quickly over 1-2 days
○ Episodes typically resolve within several weeks
● Major depression
○ Similar to unipolar major depression
○ Dysphoria
○ slowing in the pace of mental and physical activity
○ Anhedonia
○ Hopelessness
○ Worthlessness
○ Uselessness
Non nobis solum nati sumus
(​Not for ourselves alone are we born​)
-Dr. Eashan Srivastava

5. “If your kid needs a role model and you ain't it, you're both fucked.”
― George Carlin
○ memory and concentration are impaired
○ Appetite is typically diminished
○ excessive guilt
○ Insomnia
○ suicidal thoughts and behavior
● Psychosis
○ delusions and hallucinations can occur during mania
● Other Psychiatric disorders
○ Anxiety disorders
○ Substance use disorders
○ Attention deficit hyperactivity disorder (ADHD)
○ Eating disorders
○ Intermittent explosive disorder
○ Personality disorders
○ Posttraumatic stress disorder
● SUICIDE
○ M/C cause of death
○ Risk factors
■ Past H/O attempted suicide
■ Hopelessness
■ Marital status of never married
■ History of having been physically or sexually abused
■ Early age of onset
■ Family history of suicide death
■ Refractory disease
APPROACH
● Complete history
○ Medical
○ Psychiatric
● Examination
○ GPE
○ mental status
● Routine Ix
Non nobis solum nati sumus
(​Not for ourselves alone are we born​)
-Dr. Eashan Srivastava

6. “If your kid needs a role model and you ain't it, you're both fucked.”
― George Carlin
○ CBC
○ LFT
○ KFT
○ TFT
○ ECG
● Screening
○ Mania/Hypomania = Mood Disorder Questionnaire
○ Depression = Patient Health Questionnaire - 9 Item (PHQ-9)
● Diagnosis
○ DSM 5
DIFFERENTIAL DIAGNOSIS
● Unipolar major depression
● Schizoaffective disorder
● ADHD
● personality disorder
Rx of Mania/hypomania
● 2 phases of Rx
○ Rx of acute mania ( mood stabilization)
○ Maintenance
● Setting
○ Inpatient
■ suicidal ideation
■ Harm to self or others
○ Outpatient
■ Good family support
■ Mild symptoms
● Drug classes
○ Lithium
○ Anticonvulsants
Non nobis solum nati sumus
(​Not for ourselves alone are we born​)
-Dr. Eashan Srivastava

7. “If your kid needs a role model and you ain't it, you're both fucked.”
― George Carlin
■ Valproate
■ CBZ
○ Antipsychotics
■ Aripiprazole
■ Haloperidol
■ Olanzapine
■ Quetiapine
■ Risperidone
○ Benzodiazepines
● First line
○ lithium alone usually not effective since Li is slow acting
○ Li + antipsychotic
○ Li + valproate
○ Li + valproate + antipsychotic
○ No head-to-head trials have compared
○ Based on
■ past response to medications
■ side effect profiles
■ comorbid general medical conditions
■ drug-drug interactions
■ Preference
■ Cost
○ Benzodiazepines
■ hypomanic or mild to moderate manic or mixed episodes and cannot
tolerate lithium, anticonvulsants, or antipsychotics
■ Lorazepam
■ Clonazepam
● Resistant patients
○ If patient fails to respond within 2-3 weeks
○ should be treated with a second medication combination
○ Generally, lithium is switched to valproate
○ Electroconvulsive therapy
■ if does not respond to four to six medication combinations
Non nobis solum nati sumus
(​Not for ourselves alone are we born​)
-Dr. Eashan Srivastava

8. “If your kid needs a role model and you ain't it, you're both fucked.”
― George Carlin
Lithium
● DOSE
○ Starting dose = 300 mg BD
○ increased by 300 to 600 mg every 7 days
○ goal is to reach a therapeutic serum level
○ target = 0.8 and 1.2 mEq/L
● Serum Levels
○ should be measured 7 days after each dose increase
○ 12 hours after the last dose
○ before the first dose of the day
● S/E
○ Nausea
○ Tremor
○ polyuria and thirst
○ weight gain
○ Hypothyroidism
Carbamazepine
● Dose
○ Starting = 100 mg to 200 mg BD
○ Increased by 200 mg every 2-4 days
○ Usual final dose of about 800 to 1000 mg per day
● S/E
○ nausea, vomiting, diarrhea
○ SIADH
○ SJS/TEN
○ leukopenia
Valproate
● Dose
○ Starting dose of 250 mg ND/TDS
○ Increased by 250 mg to 500 mg every 1-3 days
Non nobis solum nati sumus
(​Not for ourselves alone are we born​)
-Dr. Eashan Srivastava

9. “If your kid needs a role model and you ain't it, you're both fucked.”
― George Carlin
○ Usual final dose 1500 mg to 2500 mg per day
● S/E
○ GI
○ hair loss
○ Hepatotoxic
○ Teratogenic
○ thrombocytopenia
MAINTENANCE Rx
● PHARMACOTHERAPY
○ First-line
■ same regimen that successfully treated the acute bipolar mood
■ Valproate
■ lithium
■ Lithium plus an anticonvulsant
■ Antipsychotic
○ Second-line
■ Lithium
■ Valproate
■ Quetiapine
■ Lamotrigine
■ Olanzapine
■ Risperidone
○ Other options
■ Carbamazepine
■ Paliperidone
■
○ DURATION
■ for many years
■ Variable
■ Factors to consider
● Number of years the patient has had bipolar disorder
● Lifetime number of mood episodes and hospitalizations
● number of suicide attempts
Non nobis solum nati sumus
(​Not for ourselves alone are we born​)
-Dr. Eashan Srivastava

10. “If your kid needs a role model and you ain't it, you're both fucked.”
― George Carlin
● PSYCHOTHERAPY
○ Adjunct to pharmacotherapy
○ help prevent relapses
○ improve medication adherence
○ for maintenance treatment
○ Not for acute mania
■ group therapy
■ Counselling
■ CBT
Rx OF BIPOLAR DEPRESSION
● Assessment for
○ risk of suicide
○ substance use
● Drug classes commonly used
○ Antidepressants
○ Lithium
○ Anticonvulsants
■ Valproate
■ Lamotrigine
○ Second-generation antipsychotics
■ Quetiapine
■ Olanzapine
■ Aripiprazole
● ECT
● Duration
○ Several weeks to months
○ Till depressive episode subsides
● Commonly used regimens
○ Fluoxetine plus olanzapine efficaciously treats bipolar depression
○ Lithium
■ Slow Onset of the antidepressant effect = 6-8 weeks
Non nobis solum nati sumus
(​Not for ourselves alone are we born​)
-Dr. Eashan Srivastava

11. “If your kid needs a role model and you ain't it, you're both fucked.”
― George Carlin
○ Lamotrigine
■ Start @ 25 to 50 mg/day
■ Usual dose 200-400 mg per day
■ S/E
● SJS/TEN
● GI
● ECT
○ For refractory cases
● Investigational approaches
○ Ketamine
○ Pregnenolone
Non nobis solum nati sumus
(​Not for ourselves alone are we born​)
-Dr. Eashan Srivastava