• A 25-year-old male is brought into the emergency room by his family when he spent over $100,000 on building supplies and was found naked in his back yard building a boat so he can sail the world to teach English to the people of England.  His family and friends said that for the last 2 weeks he had been increasingly grandiose, had been sleeping 3 hours per night, and had not gone to work.  Prior to this episode the patient had been relatively normal, however he had experienced a bout of depression 12 months ago.  The patient's speech seems pressured as he began to explain his idea to solve world homelessness with his program "Hammocks for the Homeless."  The patient's wife further offers that he has had a significantly increased sexual drive lately.  His urine tox screen was negative in the ED.
  • Epidemiology
    • seen in 1% of population
    • genders equally affected
    • often presents in young people (most common onset between 20-30 years)
  • Subtypes
    • bipolar I
      • manic episode with or without major depressive episodes
    • bipolar II
      • hypomanic episodes with at least one major depressive episode
    • rapid cycling
      • > 4 episodes of mania/depression/mixed within 1 year
    • cyclothymic
      • alternating hypomanic episodes with dysthymia
        • psychotherapy is best initial step in management
        • some evidence suggests valproic acid is better than lithium for these patients
  • Symptoms
    • manic symptoms
      • DIG FAST
        • Distractibility
        • Insomnia
        • Grandiosity
        • Flight of Ideas
        • Agitation
        • Sexual indiscretions/pleasurable activities
        • Talking (pressured speech)
    • hypomanic symptoms
      • similar but does not lead to marked impairment
      • no psychotic symptoms present
      • impulsivity is present
  • Diagnosis
    • episodes should last > 1 week and be continous
    • must rule out cocaine or amphetamine use
      • always do a urine toxicology for patients presenting with mania
  • Lithium  
    • first-line mood stabilizer (can take 1 week to work)
    • check creatinine before initiating therapy 
    • renal failure, hyponatremia, and dehydration all increase likelihood of lithium toxicities 
    • can cause hypothyroidism, and Epstein's anomaly in pregnant patients
    • shown to have a reduction in mortality from suicide
  • Hospitalization
    • often involuntary as manic patients do not recognize their illness
  • Benzodiazepines
    • may assist in acute sedation if patient is agitated
  • Antiepileptics  
    • valproate (useful for patients with renal dysfunction) or carbamazepine 
      • second line mood stabilizers
      • atypical antipsychotics can also be used (risperidone can be first-line
      • may begin antidepressant therapy only after mood stabilizers are started
    • lamotrigine also used (can be first-line)
    • haloperidol 
      • used as a first-line of treatment in pregnant patients
      • first-line in acute mania in patients with severe symptoms
  • Atypical antipsychotics
    • quetiapine or olanzapine 
      • can be used as second line
      • side effects of weight gain, thus often avoided in obese patients
  • SSRI's
    • can induce mania in patient's being that have been misdiagnosed with only depression
Prognosis, Prevention, and Complications
  • Prognosis 
    • worse than major depression
    • high prevalence of alcohol/substance abuse
    • high risk of suicide - worst during a mixed episode 
      • lithium is the only drug shown to reduce mortality from suicide (2015)
  • Prevention
    • if less than 3 lifetime relapses, it is possible to treat for 1 year followed by a mood stablizer taper 
    • if 3 or greater lifetime relapses, it is necessary to remain on lifetime mood stabilizer treatment

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