ICD-10 code: F31.9
Bipolar I Disorder (BPI) is part of a cluster of diagnoses called the bipolar and related disorders. Bipolar and related disorders are a group of psychiatric conditions that include:
These disorders are characterized by the occurrence of discrete mood episodes, including the presence of mania (in bipolar I disorder), hypomania (in bipolar II disorder), or hypomanic symptoms that do not meet full diagnostic criteria for hypomania or mania (in cyclothymic disorder).
An individual experiencing mania or hypomania may experience a significantly decreased need for sleep (e.g., feeling rested after only a few hours of sleep), inflated self-esteem or grandiosity, an increase in goal-directed activity (e.g., starting new projects at work or home), pressured speech, and other symptoms. Most individuals with bipolar and related disorders also experience discrete periods of depression, which are generally characterized by sadness or loss of interest, fatigue, difficulty concentrating, and/or sleep or appetite disturbance. To be diagnosed with a bipolar-related disorder, these mood symptoms must represent a clear change from normal (baseline) functioning.
The bipolar and related disorders differ from each other in the duration, severity, and types of symptoms that the individual experiences. Individuals with bipolar I disorder experience discrete manic episodes, in which manic symptoms last a week or longer, require hospitalization, or are accompanied by psychotic symptoms.
A history of a major depressive episode is not required for a bipolar I diagnosis, but such an episode will occur in the majority of individuals with bipolar I disorder. Individuals with bipolar II disorder experience hypomanic episodes, in which manic symptoms last at least four days, are not severe enough to cause marked impairment or necessitate hospitalization, and are not accompanied by psychotic features. A bipolar II diagnosis requires a history of at least one major depressive episode. Finally, individuals with cyclothymic disorder experience numerous periods of hypomanic symptoms and depressive symptoms that do not meet criteria for hypomanic and depressive episodes, respectively.
BPI is a psychiatric disorder that affects approximately 1% of adults. BPI is characterized primarily by the presence of manic episodes. Manic episodes are a distinct period of at least one week in which mood is abnormally and persistently elevated or irritable and there is an abnormal and persistent increase in goal-directed activity or energy.
During the manic episode, at least three of the following symptoms occur (four symptoms if the mood is only irritable):
Although not necessary for diagnosis, an individual with BPI will often have a history of one or more major depressive episodes. These are characterized by depressed mood or loss of interest, as well as at least four of the following symptoms, which occur nearly every day for two weeks or longer:
Psychotic features such as delusions or hallucinations can also occur during manic or depressive episodes in BPI. Psychotic features can be mood-congruent (e.g., delusions that one is destined to save humanity during a manic episode) or mood-incongruent. If psychotic features are present along with manic symptoms, the episode is by definition manic rather than hypomanic, independent of duration or impairment.
Sometimes mixed episodes can occur, where the individual meets criteria for both a manic episode and a major depressive episode concurrently. Typically, the individual with BPI will also have periods of euthymia, where no significant mood symptoms are present.
BPI severity can range from mild to debilitating. In severe cases, BPI can lead to inability to work, attend school, or make independent financial or medical decisions. Oversight by a conservator may be needed in some cases. BPI can also cause serious problems in interpersonal relationships. Many people with BPI also have other psychiatric conditions, most commonly anxiety disorders. Substance abuse may also occur, particularly during manic episodes.
BPI is characterized by abnormalities of brain function which are thought to contribute to symptoms. In particular, evidence points to hypoactivation in several regions of the prefrontal cortex, which are involved in executive functioning and regulation of emotion. Hyperactivation of limbic structures involved in memory and emotion processing, including the hippocampus and amygdala, has also been observed. In addition, heightened responsiveness to reward, particularly during manic episodes, is thought to contribute to the persistence of manic symptoms. The disorder has a genetic component, although having a genetic predisposition to BPI does not necessarily mean that someone will develop BPI.
BPI is generally thought to be a chronic disorder, but it can be managed effectively. Published treatment guidelines for BPI include those from the American Psychiatric Association, the Society of Clinical Psychology, and the National Institute for Clinical Excellence. BPI generally should not be managed in primary care; if primary care management is to occur, it should be only in consultation with a specialist. In all cases, consider hospitalization in the case of moderate to severe manic episodes.
First Line Treatments
In the case of a severe manic or mixed episode, combined pharmacological treatment with lithium plus an atypical antipsychotic such as olanzapine, risperdone, or quetiapine is the first-line treatment. For a less severe episode, monotherapy with lithium, valproate, or an atypical antipsychotic may be sufficient. Short-term adjunctive treatment with a benzodiazepine may also be helpful.
In the case of a bipolar depressive episode, lithium or lamotrigine are considered first-line treatments. Antidepressant monotherapy is not recommended, as this may trigger manic symptoms.
Augmentation of first-line pharmacological interventions with psychotherapy is also indicated. Psychological treatments with evidence of efficacy include:
Second Line Treatments
In cases of nonresponse to first-line treatment or "breakthrough" episodes despite continued pharmacological treatment, optimization of the medication dose should be the first intervention. Re-introduction of an atypical antipsychotic may also be warranted.
During a manic episode: When first-line treatments of an optimal dose are not sufficiently effective, the addition of another first-line medication may be warranted. Alternative medications for augmentation during a manic episode include:
During a depressive episode: augmentation with an antidepressant may be considered, but the individual should be closely monitored for the emergence of manic symptoms. Adjunctive medications to be considered may include:
Electroconvulsive therapy (ECT), in which small electrical currents are used to trigger a brief seizure, may also be provided as an augmentation strategy. ECT may be indicated if the individual is pregnant, in the case of severe, treatment-resistant mania or depressioin, or in the case of a mixed episode.
Additional Treatments to Consider
Preliminary evidence suggests that the following strategies, while not a substitute for the more well-validated treatments described above, might be considered to assist with depressive symptoms. However, some of these treatments have been evaluated only in the context of unipolar depression; therefore, the risk of triggering a manic episode should be carefully weighed against the potential benefits.