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Bipolar disorder

What's new

Added 2023 VA/DoD, 2023 WHO, 2021 AAFP, and 2016 BAP guidelines for the diagnosis and management of bipolar disorder.

Background

Overview

Definition
BD is a group of affective disorders characterized by depressive and manic or hypomanic episodes. The disorders include BD type I (depressive and manic episodes), BD type II (depressive and hypomanic episodes), cyclothymic disorder (hypomanic and depressive symptoms that do not meet criteria for depressive episodes), and BD not otherwise specified (depressive and hypomanic-like symptoms that do not meet the diagnostic criteria for any of the aforementioned disorders).
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Pathophysiology
The pathophysiology of BD is complex and not fully understood. It is believed to be multifactorial, resulting from the interplay of genetic and environmental factors and leading to disturbances in neuronal-glial plasticity, monoaminergic signaling, inflammatory homeostasis, cellular metabolic pathways, and mitochondrial function.
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Epidemiology
The lifetime prevalence of BD globally is estimated at 0.6% for bipolar I disorder, 0.4% for bipolar II disorder, 1.4% for subthreshold BD, and 2.4% for the bipolar spectrum disorder. The weighted average prevalence of bipolar spectrum disorders in children and adolescents aged 7-21 years is estimated at 2.06%.
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Risk factors
Risk factors for BD include genetic predisposition, with a high heritability of approximately 70%, and a shared genetic risk with other mental and medical disorders. Bipolar I has a closer genetic association with schizophrenia, while bipolar II has a closer genetic association with major depressive disorder. Environmental risk factors such as childhood maltreatment are also associated with a more complex presentation of BD. Additionally, certain single-nucleotide polymorphisms and genetic variants, such as those in the CACNA1C, NCAN, DRD4, ANK3, DAOA, COMT, and MTHFR genes, have been identified as risk factors for BD.
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Disease course
The clinical course of BD is characterized by recurrent episodes of depression and mania or hypomania, often starting in young adulthood. Manic and hypomanic episodes are characterized by a distinct change in mood and behavior during discrete time periods, often presenting with symptoms such as inflated self-esteem or grandiosity, decreased need for sleep, pressured speech, racing thoughts, flight of ideas, distractibility, increased goal-directed activity, and excessive involvement in activities with a high potential for painful consequences. Depressive episodes in BD are similar to major depressive episodes, characterized by symptoms such as depressed mood, markedly diminished interest or pleasure in all, or almost all, activities, significant weight loss or gain, insomnia or hypersomnia, psychomotor agitation or retardation, fatigue or loss of energy, feelings of worthlessness or excessive or inappropriate guilt, diminished ability to think or concentrate, or indecisiveness, and recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.
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Prognosis and risk of recurrence
Life expectancy in BD is reduced by approximately 10-20 potential years of life, mainly due to excess deaths from CVD and suicide.
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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of bipolar disorder are prepared by our editorial team based on guidelines from the United States Department of Defense (DoD/VA 2023), the World Health Organization (WHO 2023), the American Academy of Family Physicians (AAFP 2021), the American Thoracic Society (ATS 2020), the British Association for Psychopharmacology (BAP 2016,2014), the The Scottish ...
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Screening and diagnosis

Indications for screening, general population: as per DoD/VA 2023 guidelines, avoid obtaining routine screening for BD in the general population.
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  • Indications for screening (positive family history)

  • Indications for screening (pregnancy)

Diagnostic investigations

Initial assessment: as per DoD/VA 2023 guidelines, consider using a validated instrument, such as the Bipolar Spectrum Diagnostic Scale, the Hypomania Checklist, or the Mood Disorder Questionnaire, to support decision-making about the diagnosis in patients with suspected BD.
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Medical management

Management of acute mania: as per DoD/VA 2023 guidelines, consider offering lithium or quetiapine as monotherapy for acute mania.
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  • Management of acute bipolar depression

  • Maintenance therapy

  • Management of comorbidities (tobacco use)

  • Management of comorbidities (alcohol use)

  • Management of comorbidities (substance use)

  • Management of comorbidities (anxiety)

  • Management of comorbidities (borderline personality disorder)

  • Management of comorbidities (hypothyroidism)

Nonpharmacologic interventions

General principles: as per DoD/VA 2023 guidelines, consider using a collaborative care model for the management of patients with BD.
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  • Psychotherapy

  • Technology-based interventions

  • Supportive care

  • Alternative and complementary therapies

Therapeutic procedures

Electroconvulsive therapy: as per DoD/VA 2023 guidelines, consider offering electroconvulsive therapy in combination with pharmacotherapy in patients with bipolar I disorder with acute severe manic symptoms requiring rapid control of symptoms.
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  • Light therapy

  • Transcranial magnetic stimulation

Specific circumstances

Adolescent patients: as per WHO 2023 guidelines, consider offering psychotropic agents (antipsychotics such as aripiprazole, olanzapine, quetiapine, and risperidone, and mood stabilizers such as lithium) in adolescent patients with current episode mania under specialist supervision, while carefully balancing effectiveness, side effects, and individual preference.
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  • Pregnant patients (screening)

  • Pregnant patients (pharmacotherapy)

  • Pregnant patients (electroconvulsive therapy)

  • Elderly patients