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Bipolar Disorder

1. Bipolar Disorder Lior Shlomov 1852

2. Background Bipolar disorder is a psychiatric condition characterized by episodes of mania (or hypomania) and major depression, interspersed with periods of normal mood and functioning. During manic episodes, patients may experience elevated mood, talkativeness, racing thoughts, and psychosis, which may endanger themselves or others. Depressive episodes are characterized by sadness, anhedonia, and hopelessness. Although episodes of mania or depression can occur at any time, they are especially triggered by environmental factors, such as lack of sleep or psychosocial stress.

3. Epidemiology Men and women are equally affected The average age of onset is 20 years. The frequency of depressive and manic episodes increases with age. General population: 1–3% First-degree relative with bipolar disorder: up to 10% Monozygotic twin: 40–70%

4. Etiology Multifactorial origin - Strong genetic component → increased risk if first-degree relative is affected. Triggers - Psychosocial stress Childhood traumatic experiences Sleep disturbances Physical illness

5. Clinical features Bipolar disorder is characterized by alternating episodes of mania (often also hypomania) and major depression, in between which individuals may be asymptomatic. Manic/hypomanic episode Symptoms include: Intense prolonged happiness (for several days) Irritability Overconfidence, risky behavior (overspending money) Decreased need for sleep Hypersexuality Psychotic features

6. Clinical features Major depressive episode: Symptoms include: Anhedonia Fatigue, sleep disturbances Frequent reports of pain, e.g., headache or stomach ache Lack of interest in activities that were previously enjoyed Feelings of worthlessness or guilt Suicidal ideation

7. Types of bipolar disorder Bipolar I disorder: at least one episode of mania. Major depressive or hypomanic episodes usually occur but are not required for diagnosis. Bipolar II disorder: at least one episode of hypomania and one major depressive episode; no previous episodes of mania (distinguishing feature from bipolar I)

8. Subtypes Cyclothymia – Persistent instability of mood involving numerous periods of depressive symptoms and periods of hypomanic symptoms Symptoms are not sufficiently severe or persistent enough to diagnose bipolar disorder. Symptoms last at least 2 years, are present at least half of the time, and are never absent for more than 2 months at a time.

9. Diagnostic approach The DSM-5 diagnostic criteria are used to identify episodes of mania, hypomania, and major depression. Bipolar I disorder: ≥ 1 confirmed episode of mania Bipolar II disorder: ≥ 1 confirmed episode of hypomania AND ≥ 1 major depressive episode AND absence of any manic episodes

10. Treatment Goals: Acute treatment: resolution of mania and psychosis (if present) in order to prevent harm to the patient and/or others Maintenance therapy: prevention of manic episodes, reduction of suicide risk, improvement in social functioning

11. Treatment-Acute treatment

12. Treatment- Maintenance therapy Indications: Consider for all patients, particularly those with a history of one or more manic episodes. Commonly used agents - Lithium (preferred): Individualize the dose according to clinical response and serum levels. Valproic acid; , lamotrigine carbamazepine Refractory or severe bipolar episodes - Combination therapy with a mood stabilizer (e.g., lithium or valproic acid) PLUS atypical antipsychotics (e.g., quetiapine, olanzapine, aripiprazole) Severe depression or predominantly depressive bipolar II disorder: Antidepressants may be started after initiating mood stabilizers.

13. Antipsychotics are the preferred initial therapy in agitated patients because of their rapid onset of action. Patients with suicidal ideation should be admitted immediately for emergency management and monitoring by a specialist. Acute mania is a psychiatric emergency that requires immediate management. Lithium has a narrow therapeutic index and doses should be individualized according to serum levels and clinical response; an overdose may result in life-threatening lithium toxicity. Lithium is contraindicated in patients with renal dysfunction.