Overview

Bipolar disorder Episodic depressed and elated moods, and increased activity (hypomania or mania).

Bipolar I disorder is characterized by at least one manic episode with or without a history of major depressive episodes.

Bipolar II disorder is characterized by one or more major depressive episodes and by at least one hypomanic episode, but no evidence of mania.

Bipolar disorder is known to be one of the most heritable psychiatric disorders.

Prevalence

Overall, 2.0% of the population screened positive for bipolar disorder.
Bipolar disorder was more common in younger age-groups, being observed in: 3.4% of 16–24 year olds.

Complications

• Suicide and deliberate self-harm

• Financial difficulties from overspending.

• Traumatic injuries and accidents.

• Sexually transmitted infections and unplanned pregnancy from disinhibition and increased libido.

• Damage to reputation, income and occupation, and relationships.

• Self-neglect, exhaustion, and dehydration.

• Exploitation by others.

• Alcohol and substance misuse.

• Harm to others

• Post partum psychosis

Prognosis

The natural history of bipolar disorder usually includes periods of remission, but relapse is common, particularly where adherence to treatment is poor.

A person with bipolar disorder will experience an average of approximately 10 episodes during their lifetime, although there is a large degree of interindividual variation.

After an episode, the risk of recurrence in 12 months is 50% and by four years the risk is 75%.

Diagnosis

Bipolar disorder should be suspected in people who present with symptoms suggestive of any combination of:

Manic episode
Elevated, expansive, or irritable mood lasting at least 7 days
AND at least three additional symptoms: increased energy, decreased need for sleep, pressure of speech, flight of ideas, extravagant plans
OR includes psychotic features: delusions (usually grandiose) or hallucinations (usually voices).

Hypomanic episode
Elevated, expansive, or irritable mood lasting at least 4 days
No marked impairment in social or occupational functioning
No hospitalization
No psychotic features.

Depressive episode
Depressed/low mood OR anhedonia (loss of pleasure in activities) for at least 2 weeks
AND at at least four additional depressive symptoms.

Mixed episode
A mixture or rapid alternation of manic and depressive symptoms

Rapid-cycling bipolar disorder
At least FOUR depressive, manic, hypomanic, or mixed episodes within a 12-month period.

Primary care investigations

Use clinical judgement to determine whether thyroid function tests, full blood count, vitamin D, or other blood tests (including a toxicology screen) are required. 

Primary care management

1. Refer for specialist mental health assessment.

2. A risk assessment should be done to determine the urgency of referral

3. Refer for urgent mental health assessment if the person presents with mania, severe depression, or if they are a danger to themselves or other people. Also consider that people with bipolar disorder may be vulnerable to exploitation or violence when in an abnormal mental state.

4. Adults with bipolar disorder treated in secondary care may be transferred back to primary care for ongoing management once their condition has stabilised.

5. Carry out physical health reviews and perform blood tests
   Fasting glucose, HbA1c.

   Lipid profile.

   Urea and electrolytes.

   Full blood count.

   Liver function tests.

   Thyroid function and calcium levels if the person is taking long-term lithium.

Secondary care management

Acute mania:

1st and 2nd line: oral antipsychotic (haloperidol, olanzapine, quetiapine, or risperidone),
3rd line: ADD on lithium or sodium valproate

Acute depression:

Quetiapine alone, or
Fluoxetine combined with olanzapine, or
Olanzapine alone, or
Lamotrigine alone.

Four weeks after the acute episode has resolved, to prevent relapses, the person is usually offered a choice to:

• Continue their current treatment for mania, or

• Start long-term treatment with lithium (+/- Valproate) to prevent relapses, or

Psychological therapies

Drug treatments

Valproate

1. Do not prescribe valproate to people with Active liver disease

2. MHRA recommends that valproate should not be prescribed to female children, female adolescents, women of childbearing potential, or pregnant women to treat bipolar disorder unless the illness is very severe and there is no effective alternative option.
   Females of childbearing potential taking valproate should be enrolled in a pregnancy prevention plan.
   Valproate is a teratogen and can cause physical birth defects and developmental disorders in children exposed in utero.

3. Monitoring
   Basline full blood count, liver function tests (LFTs), and body weight or body mass index (BMI)

   Ensure that FBC, LFTs, INR, BMI are measured 6 months after treatment has been initiated, and every 12 months thereafter.

   Valproate levels are not routinely measured unless there is evidence of ineffectiveness, poor compliance, or toxicity is suspected.

Lithium

1. Always prescribe lithium (tablet or liquid) by brand name as preparations vary widely in bioavailability.

2. The lithium dose is usually adjusted to achieve a plasma level of 0.6 mmol/L to 1 mmol/L.

3. Do not prescribe lithium to people with: Cardiac disease, Clinically significant renal impairment, Untreated or untreatable hypothyroidism, Brugada syndrome or family history of Brugada syndrome, Low sodium levels, Addison's disease.

4. Adverse side-effects:
   Nausea, diarrhoea, vertigo, muscle weakness, and a 'dazed' feeling.
   Fine hand tremors, polyuria, and polydipsia may persist.
   Hypothyroidism: Levothyroxine replacement is usually indicated.
   Hyperparathyroidism: lithium use has been associated with hypercalcaemia.
   Nephrotoxicity
   Renal tumours
   Rhabdomyolysis

5. Key drug interactions of lithium: diuretics, ACE inhibitors, NSAIDs, Haloperidol Carbamazepine: ALL increase lithium toxicity

6. Monitoring
   Lithium levels are normally measured one week after starting treatment, one week after every dose change, and weekly until the levels are stable.
   Once levels are stable, Lithium levels are usually measured every 3 months (measure Lithium levels 12 hours post-dose).
   Every 6 months measureBMI, U&Es eGFR, calcium and thyroid function tests

7. Lithium toxicity

Signs:
hyper-reflexia
hyperextension of limbs
syncope
toxic psychosis
seizures
polyuria, renal failure, electrolyte imbalance, dehydration
circulatory failure
coma

Symptoms:
diarrhoea, vomiting, anorexia, muscle weakness, lethargy, dizziness
ataxia, lack of coordination
tinnitus
blurred vision
coarse tremor of the extremities and lower jaw
muscle hyper-irritability
choreoathetoid movements
dysarthria
drowsiness.

People taking lithium should be advised:

• To carry a lithium card.

• That regular blood tests are important and the results should be recorded in their lithium record booklet.

• About what adverse effects to expect.

• How to recognize the symptoms of lithium toxicity.

• Not to take over-the-counter nonsteroidal anti-inflammatory drugs.

• That episodes of diarrhoea or vomiting, or any form of dehydration, will lead to sodium depletion and therefore increased plasma lithium levels.

• To maintain their fluid intake, particularly after sweating (for example, after exercise, in hot climates, or if they have a fever), if they are immobile for long periods, or if they develop a chest infection or pneumonia.

• That if a dose is missed they should take it as soon as possible; but if yesterday's dose was missed then they should not double today's dose.

• Not to stop taking lithium abruptly, and that non-compliance may lead to a relapse.

• Women of childbearing age should be advised to use reliable contraception.