🔑 Key Learning

  • Bipolar affective disorder involves episodes of mania wth or without a history of depressive episodes
  • Management:
    • Antipsychotics are first-line for acute mania
      • Haloperidol, Quetiapine, Risperidone, Olanzapine
    • Lithium is commonly used for long-term prevention/maintenance 

🌞 Mania

👀 Clinical Features

  • Abnormally elevated mood
  • Hyperactivity, agitation, restlessness, irritable 
  • Pressured speech and flight of ideas
  • Disinhibition, increased libido
  • Risky behaviours (e.g. gambling, excessive spending)
  • May include psychotic symptoms:
    • Grandiose delusions
    • Auditory hallucinations

Duration:

  • Symptoms last ≥7 days and cause significant functional impairment

🌤️ Hypomania

👀 Clinical Features

  • Milder elevation of mood
  • Irritability, hyperactivity, talkativeness
  • Over-familiarity, increased sociability
  • No psychotic features
  • Less functional impairment than mania

🔁 Mixed Episode

  • Rapidly alternating symptoms of depression and mania/hypomania

🧠 Bipolar Affective Disorder (BAD)

📋 Diagnostic Subtypes (DSM-5)

  • Type 1 BAD:
    • At least one manic episode
    • Depressive episodes may or may not be present
  • Type 2 BAD:
    • At least one hypomanic episode
    • One or more depressive episodes
    • No history of mania

💊 Management of Mania / Mixed Episodes

Stepwise Acute Management (NICE)

Step 1:

  • Start an oral antipsychotic:
    • Haloperidol
    • Quetiapine
    • Risperidone
    • Olanzapine

Step 2:

  • If not tolerated/effective → switch to an alternative antipsychotic

Step 3:

  • If symptoms persist → add lithium
    • Sodium valproate can be considered if lithium unsuitable
      • Avoid in women of child-bearing potential

Other considerations:

  • Taper and stop any antidepressants

🌧️ Management of Bipolar Depression

First-line options:

  • Quetiapine
  • Lamotrigine
  • Olanzapine
  • Olanzapine + fluoxetine combination

🔁 Long-Term Management

Maintenance (after 4 weeks of stability)

  • Continue the antipsychotic used in acute phase
    OR
  • Start lithium for long-term relapse prevention
    • Add valproate if monotherapy insufficient

Psychological Interventions

  • Offer CBT or structured psychological therapy to all patients with BAD
  • High-intensity therapy if depression is prominent

💊 Lithium

Indication
Mood stabiliser for bipolar affective disorder

Side effects

  • Nausea, vomiting
  • Fine tremor (coarse tremor = toxicity)
  • Nephrogenic diabetes insipidus
  • Hypothyroidism
  • Weight gain
  • Idiopathic intracranial hypertension
  • Hyperparathyroidism and hypercalcaemia

Monitoring

  • Lithium levels: 1 week after initiation and after dose changes
  • Once stable: every 3 months
  • Every 6 months: BMI, U&Es, calcium, TSH
  • If worsening renal function, monitor lithium more frequently

📝 Exam Clues & Clinchers

  • Elevated mood + pressured speech + risky behaviour + 7 days → think mania
  • Same symptoms but milder + no psychosis + functioning intact → hypomania
  • First-line for acute mania → antipsychotics (quetiapine, risperidone, etc.)
  • Bipolar depression → quetiapine or lamotrigine
  • Maintenance → lithium or continue antipsychotic 
  • Atypical antipsychotics → Weight gain, dyslipidaemia, insulin resistance
  • Lithium → tremor, hypothyroidism 

🔗 Useful Links and References

NICE CKS. Bipolar Disorder. [Last updated April 2024]