Snapshot A 25-year-old man seeks help from his psychiatrist. He has a history of bipolar I disease and had been on lithium for many years. He has had primarily manic episodes in the past which required mood stabilization. Lately, he reports he has been feeling depressed. He is preoccupied about thoughts of hurting himself. He stopped taking his lithium medication consistently, taking it only when he feels it may be beneficial. He also reports sleeping excessively and feeling very fatigued. He felt a huge amount of guilt towards his parents who had high hopes for him to become a doctor. His psychiatrist contemplates switching mood stabilizers. Introduction Overview bipolar disorder is characterized by episodes of mania and depression treatment is mood stabilizers or atypical antipsychotics bipolar I at least 1 manic episode, with or without a hypomanic or depressive episode bipolar II hypomanic episode and depressive episode Epidemiology Incidence lifelong prevalence range from 0.9-2.1% Demographics mean age of onset is 21 years women often cycle through manic and depressive episodes more frequently Risk factors other mood disorders Etiology Pathogenesis mechanism may be a genetic susceptibility for bipolar disorder may be atrophy in the brain Presentation Symptoms mood may normalize between episodes, and patient may be fully functional during this time using antidepressants may destabilize mood and trigger an episode manic episodes (at least 1 week duration and causes marked impairment in function) or hypomanic episodes (at least 4 days duration and may not be severe enough to cause dysfunction) with 3 or more of the following grandiosity decreased sleeping excessive talking and pressures speech racing thoughts and ideas distractibility increased level of goal-focused activity at home, work, or sexually excessive pleasurable activities depressive episodes (2 weeks duration) with 5 or more of the following, including either depressed mood or loss of pleasure or interest in activities depressed mood loss of pleasure or interest in activities weight loss or gain or appetite loss or gain hypersomnia or insomnia psychomotor retardation or agitation loss of energy or fatigue feelings of worthlessness or excessive guilt decreased ability to concentrate or make decisions preoccupation with death or suicide either phase may have psychotic features Physical exam psychomotor agitation or depression Differential Cyclothymic disorder key distinguishing factor presents similarly but with milder symptoms and lasts 2 years or longer Treatment Non-medical psychotherapy indications may help decrease recurrence rates or help improve quality of life inpatient admission indications suicidal behavior or psychosis electroconvulsive therapy (ECT) indications refractory to medications Medical mood stabilizers indications first-line avoid anti-depressants (can worsen symptoms) drugs lithium renal failure, hyponatremia, and dehydration increase the likelihood of lithium toxicities valproic acid carbamazepine lamotrigine atypical antipsychotics or typical antipsychotics indications if there are features of psychosis drugs ziprasidone quetiapine risperidone aripiprazole haloperidol used in pregnant women Complications Increased risk of suicide