Am Fam Physician. 2021;103(4):227-239
Patient information: A handout on this topic is available at https://familydoctor.org/condition/bipolar-disorder.
Author disclosure: No relevant financial affiliations.
Bipolar disorders are common, recurrent mental health conditions of variable severity that are difficult to diagnose. Affected individuals have higher rates of other mental health disorders, substance use disorders, and comorbid chronic medical illnesses. New diagnostic criteria and specifiers with attention on mixed features and anxious distress aid the physician in recognizing episode severity and prognosis. Physicians should consider bipolar disorder in any patient presenting with depression. Pharmacotherapy with mood stabilizers, such as lithium, anticonvulsants, and antipsychotics, is a first-line treatment that should be continued indefinitely because of the risk of patient relapse. Active lifestyle approaches include good nutrition, exercise, sleep hygiene, and proper weight management. Monotherapy with antidepressants is contraindicated during episodes with mixed features, manic episodes, and in bipolar I disorder. Ongoing management involves monitoring for suicidal ideation, substance use disorders, treatment adherence, and recognizing medical complications of pharmacotherapy. Psychotherapy is a useful adjunct to pharmacotherapy. Patients and their support systems should be educated about the chronic nature of this illness, possible relapse, suicidality, environmental triggers (e.g., seasonal light changes, shift work, other circadian disruption), and the effectiveness of early intervention to reduce complications.
Bipolar disorders comprise recurrent episodes of elevated mood and depression.1 The relapse rate is more than 70% over five years.2 Definitions of the various types of bipolar disorders are provided in Table 13,4; diagnostic criteria are listed in Table 2.3 Hypomania can occur in bipolar I and II disorders, whereas mania, which may include psychosis, appears only in bipolar I disorder. The nature and prognosis of the current episode and the likelihood of future ones can be described with specific attributes3 (Table 33–5 ).
| Disorder | Definitions |
|---|---|
| Bipolar I disorder | Manic or mixed feature episode with or without psychosis and/or major depression |
| Bipolar II disorder | Hypomanic episode with major depression; no history of mania, but can have a history of hypomania |
| Cyclothymia | Hypomanic and depressive symptoms that do not meet bipolar II disorder criteria, no major depressive episodes, occurring over two years, with no more than two months free of symptoms |
| Bipolar disorder, not otherwise specified | Does not meet criteria for major depression, bipolar I disorder, bipolar II disorder, or cyclothymia (e.g., less than one week of manic symptoms, without psychosis or hospitalization) |
| Bipolar disorder, mixed features type or major depressive disorder, mixed features type | Mixed type, also known as mixed features, is a recent specifier that includes concurrent features of hypomania or mania and depression; patients who do not meet full criteria for bipolar disorders remain categorized as having unipolar depression |
| Substance-induced mania (include name of substance) | Examples include steroids, alcohol, cocaine, or prescription antidepressants |
| Unspecified | Used for suspicion (e.g., in emergency department) |
| Diagnostic criteria For a diagnosis of bipolar I disorder, it is necessary to meet the following criteria for a manic episode. The manic episode may have been preceded by and may be followed by hypomanic or major depressive episodes. | |||
Manic episode
Note: A full manic episode that emerges during antidepressant treatment (e.g., medication, electroconvulsive therapy) but persists at a fully syndromal level beyond the physiologic effect of that treatment is sufficient evidence for a manic episode and, therefore, a bipolar I diagnosis. Note: Criteria A–D constitute a manic episode. At least one lifetime manic episode is required for the diagnosis of bipolar I disorder. | |||
Hypomanic episode
Note: A full hypomanic episode that emerges during antidepressant treatment (e.g., medication, electroconvulsive therapy) but persists at a fully syndromal level beyond the physiologic effect of that treatment is sufficient evidence for a hypomanic episode diagnosis. However, caution is indicated so that one or two symptoms (particularly increased irritability, edginess, or agitation following antidepressant use) are not taken as sufficient for diagnosis of a hypomanic episode, nor necessarily indicative of a bipolar diathesis. Note: Criteria A–F constitute a hypomanic episode. Hypomanic episodes are common in bipolar I disorder but are not required for the diagnosis of bipolar I disorder. | |||
Major depressive episode
Note: Criteria A–C constitute a major depressive episode. Major depressive episodes are common in bipolar I disorder but are not required for the diagnosis of bipolar I disorder. Note: Responses to a significant loss (e.g., bereavement, financial ruin, losses from a natural disaster, a serious medical illness or disability) may include the feelings of intense sadness, rumination about the loss, insomnia, poor appetite, and weight loss noted in Criterion A, which may resemble a depressive episode. Although such symptoms may be understandable or considered appropriate to the loss, the presence of a major depressive episode in addition to the normal response to a significant loss should also be carefully considered. This decision inevitably requires the exercise of clinical judgment based on the individual's history and the cultural norms for the expression of distress in the context of loss. The occurrence of the manic and major depressive episode(s) is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder. Specify: | |||
| With anxious distress | With melancholic features | With mood-incongruent psychotic features | With seasonal pattern |
| With mixed features | With atypical features | With catatonia | |
| With rapid cycling | With mood-congruent psychotic features | With peripartum onset | |
| DSM-5 specifiers | Bipolar I disorder | Bipolar II disorder | Major depressive disorder |
|---|---|---|---|
| Anxious distress Associated with higher suicide risk, longer duration of illness, and greater likelihood of treatment nonresponse. It requires two or more of the following: Feeling keyed up or on edge, feeling restless, difficulty concentrating because of worry, fear that something awful might happen, feeling of losing control | Yes | Yes | Yes |
| Atypical features Sleeps more, eats more, feels “heavy” or “leaden” | Possible, when depressed | Possible, when depressed | Possible, depending on type of depression |
| Catatonic | Yes | Yes, when depressed only; otherwise, bipolar I disorder | Yes |
| Current episode severity Mild: symptoms sufficient to meet only criteria for diagnosis with mild functional impairment Moderate: between mild and severe Severe: symptoms causing severe distress and functional impairment | Yes | Yes | Yes |
| Melancholia | Yes, if depressed | Yes, if depressed | Yes |
| Mixed features state Symptoms of depressed mood and mania or hypomania within the same episode | Yes, can be triggered or worsened by the use of antidepressants | Yes | Yes, recovery from depression can manifest first with return of energy before mood improvement, which can look similar and is a vulnerable time for patients |
| Peripartum onset | Yes | Yes | Yes |
| Psychotic features Mood congruent or incongruent, which is defined as mood state consistent with depressed mood or manic state or inconsistent with state | Yes | Yes, when depressed only; otherwise, bipolar I disorder | Yes |
| Rapid cycling Can be applied to bipolar I disorder if the patient has had at least four mood episodes in the previous 12 months and if the episodes were demarcated by partial or full remission for at least two months or a switch to an episode of opposite polarity (e.g., major depressive episode to manic episode)* | Yes | No | No |
| Seasonal component Specifier for course of illness | Yes, often hypomania or mania triggered in the spring or with change in light or shift work | Yes, often hypomania triggered in the spring or with change in light or shift work | Yes, if it has a component of seasonal affective disorder |
Epidemiology
Bipolar disorders, affecting more than 1% of the world's population, have no predilection for race, sex, ethnicity, or socioeconomic status.4 Bipolar I disorder has a higher lifetime incidence than bipolar II disorder (0.6% and 0.4%, respectively).6 The mean age at onset is 18 years in bipolar I disorder and 22 years in bipolar II disorder.7
One-fourth of patients presenting with depression or anxiety in a primary care setting have been diagnosed with a bipolar disorder.8 Three-fourths of patients with bipolar disorder have a history of three additional and concurrent mental health conditions, most commonly anxiety disorders, impulse control and attention-deficit/hyperactivity disorders, and substance use disorders, which are associated with worse outcomes.9,10 One-third of patients who have been diagnosed with bipolar disorder will attempt suicide in their lifetime, 16% will have attempted suicide within the past year, and 6% to 7% complete suicide.11,12 Twenty-six percent of suicides occur within six weeks of a hospital discharge.11,12 Patients who have anxious distress have a higher risk of suicide, longer illness duration, and poorer response to medication.13
Etiology
Bipolar disorders are multifactorial conditions with a genetic predisposition affected by stress and the environment. Children of parents with bipolar disorders have a 4% to 15% risk of being affected, compared with a less than 2% risk in children of parents without bipolar disorder.12 Acute stressors are often associated with the initial onset of illness and sometimes with recurrence.5 These include stressful life events, adverse childhood events and trauma, suicide of a family member, and disruptions in the sleep cycle.14 Biologic susceptibility, central and peripheral nervous system inflammation, abnormal endocrine and neuronal pathways, and mitochondrial dysfunction inheritance patterns have been implicated in bipolar disorders.15,16
Clinical Presentation
Patients typically present for treatment with depression or anxiety or with mixed features, which include concurrent mania and depression.2,8 This depression may be indistinguishable from unipolar depression12 (Table 412,17,18 ) and often starts in early childhood.19 Women are more susceptible during hormonal fluctuations, such as during menses, childbirth, and menopause.20 Diagnosis may be delayed because a series of depressive episodes may occur before a mixed features, manic, or hypomanic episode manifests. Patients typically do not present for care with hypomania because, despite possible negative consequences, it is often seen as a desirable state by the patient.21 Physicians should specifically ask patients who are depressed about symptoms of mania or hypomania (Table 4).12,17,18 Shift work, travel across time zones, and seasonal light changes such as during daylight savings time can trigger hypomania and mania. As many as 25% of patients may present with a seasonal pattern.22,23
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