Snapshot 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. Introduction 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 Presentation 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 Evaluation 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 Treatment 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 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 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