Bipolar Disorder in Adults: Information for Primary Care

Summary: Bipolar disorder is an mental health condition where people have periods of mania / hypomania and periods of depression. When there are obvious mania symptoms, it can be easier to identify. Unfortunately, it can also be challenging to recognize. Consider bipolar in patients who have had poor response to multiple antidepressant trials, and who have comorbid anxiety/depression. Primary care providers can make a significant difference by recognizing and connecting patients with appropriate resources and treatments. Psychiatrists and primary care providers alike may be involved with starting treatment for bipolar disorder as well as follow-up and monitoring of medication treatment.

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Case of Hypomania: “She vacuums in the middle in the middle of the night”

B. is a 35-year-old woman who presents along with her spouse.

For the past 3-weeks, she has had increased energy, libido, and staying up the whole night, yet she appears to have tons of energy the next day. She still appears able to function at work and home, though is a bit more erratic.

What do you do?

You wonder about hypomania based on mood symptoms, but which are not severe enough to be mania.
As her symptoms are not severe enough to justify inpatient care, you decide to manage her as an outpatient.
You start her on Quetiapine 50 mg at bedtime with plans to follow up in a week.
You let the family know that if symptoms worsen, they can
- Call the crisis line (which includes mobile crisis services),
- Bring her to the nearest Emergency Department, and/or
- Contact emergency medical service (EMS).

Case of Mania: “I’m scared of my husband... He's not himself..."

M is a 35-year-old man with a strong family of bipolar disorder (mother, grandfather) who you have been treating for depression.

His wife calls your office calls your office frantically to tell you that, rather abruptly, he has:

Become very angry, is talking too fast and is not sleeping,
Plans to spend all their money on a business that he has no experience with,
Become threatening towards her and others, is driving at high speeds and has extreme “road rage”.

You can hear him in the background, and his wife can put you on the phone briefly with him. He denies anything is wrong but does agree that he hasn't slept in days.

What do you do?

You wonder about a manic episode, given the very severe mood symptoms.
Given the acute safety concerns (e.g., physical and financial), you decide to fill out a Form 1 so that the police can bring him to the emergency department to be assessed.
You contact triage at the Emergency Department and give them a heads up.

Epidemiology

Up to 20% of depressed patients presenting to primary care physicians have some form of bipolar disorder (CANMAT).
Peak age of onset: Age 17-21 (CANMAT)

Screening

Consider screening patients with risk factors such as:
- Relatives with bipolar disorder
- No response to 3 or more antidepressant trials
- Comorbid anxiety/obesity
- Patients with suspected or already diagnosed depression

Screening Tools

Mood Disorder Questionnaire (MDQ)
- A brief self-report instrument that takes 5 minutes.
- Positive screens should receive a more comprehensive evaluation.
- Sensitive for bipolar I (depression and mania); however, less sensitive for other bipolar disorders such as bipolar II (depression and hypomania) and bipolar unspecified
- Available freely online:
  www.integration.samhsa.gov/images/res/MDQ.pdf
  http://bipolar.stanford.edu/mdq.html

History / Screening Questions

DIG FAST mnemonic, as in a person with mania who is digging very fast:
- D)istractibility: Are more distractible than usual?
- I)mpulsivity/irritability: Are you more impulsive than usual?
- G)randiosity: Do you have special skills or abilities others don’t have?
- F)light of ideas: Are your thoughts faster than usual?
- A)ctivity increased: Are you doing more activities or find yourself busier than usual?
- S)leep decreased: Have you had less need to sleep lately?
- T)alkative: Have you been more talkative than usual?

Diagnosis (Dx)

Bipolar disorder is a clinical diagnosis based on history and physical finding
There are no diagnostic lab investigations, though they may be useful for ruling out medical conditions
Diagnosis is often delayed because a series of depressive episodes may occur before a manic or hypomanic episode occurs
When diagnosing depression, screen for symptoms of bipolar to ensure the patient is not actually suffering from bipolar disorder

Main Bipolar Disorders

Bipolar I

Past or present Manic episode (i.e. elevated/irritable mood lasting more than one week, along with increased energy/activity)

Severe enough to cause marked impairment, such as requiring hospitalization)

May also have periods of depression

Bipolar II

Past or present Hypomanic episode (i.e. elevated/irritable mood lasting at least 4 days, with increased energy/activity)

Not severe enough to cause marked impairment (such as requiring hospitalization)

May also have periods of depression

Cyclothymic Disorder

Subthreshold disorder with symptoms of depression and hypomania, but not sufficient to meet criteria for major depression or hypomanic disorder

DSM-5 Bipolar Disorders

More...

Bipolar I (DSM-5 definition)

A. Criteria have been met for at least one manic episode (E.g. Period of elevated/irritable mood lasting more than one week, along with increased energy/activity and severe enough to cause marked impairment (e.g. requiring hospitalization)

B. Symptoms are not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorders.

Manic Episode (DSM-5 definition)

A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goal-directed activity or energy. Lasting ≥ 1 week and present most of the day, nearly every day (or any duration if hospitalization is necessary)

B. During the period of mood disturbance and increased energy and activity, ≥3 of the following symptoms (≥4 if the mood is only irritable)

Inflated self-esteem or grandiosity
Decreased need for sleep
More talkative than usual or pressure to keep talking
Flight of ideas or subjective experience that thoughts are racing
Distractibility (attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed
Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation (purposeless non-goal-directed activity)
Excessive involvement in activities that have a high potential for painful consequences (engaged in unrestrained buying sprees, sexual indiscretions, or foolish business investments)

C. Marked impairment in function or severe enough to require hospitalization to prevent harm to self or others, or there are psychotic features.

D. Not due to a substance (drug abuse, medication, other treatment) or to another medical condition

Bipolar II

A. Criteria have been met for at least 1 hypomanic episode and at least one major depressive episode

B. There has never been a manic episode (otherwise, it is, by definition, Bipolar I)

C. Symptoms are not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder

D. Clinically significant distress or impairment in social, occupational, or other important areas of functioning

Hypomanic Episode

A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy. Lasting ≥ 4 consecutive days and present most of the day, nearly every day

B. During the period of mood disturbance and increased energy and activity, ≥3 of the following symptoms (≥4 if mood is only irritable)

Inflated self-esteem or grandiosity
Decreased need for sleep
More talkative than usual or pressure to keep talking
Flight of ideas or subjective experience that thoughts are racing
Distractibility (attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed
Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation (purposeless non-goal-directed activity)
Excessive involvement in activities that have a high potential for painful consequences (engaged in unrestrained buying sprees, sexual indiscretions, or foolish business investments)

C. The unequivocal change in functioning is uncharacteristic of the individual when not symptomatic.

D. Disturbance in mood and change in functioning are observable by others.

E. Not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization. If there are psychotic features, the episode is, by definition, manic.

F. Not due to effects of a substance (drug abuse, medication, other treatment)

Major Depressive Episode

A. ≥5 of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure

1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (feels sad, empty) or observation made by others (appears tearful)

2. Diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day

3. Significant weight loss when not dieting or weight gain (change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day

4. Insomnia or hypersomnia nearly every day

5. Psychomotor agitation or retardation nearly every day

6. Fatigue or loss of energy nearly every day

7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day

8. Diminished ability to think or concentrate, or indecisiveness, nearly every day

9. Recurrent thought of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide

B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning

C. The episode is not attributable to the physiological effects of a substance or another medical condition

Differential Diagnosis (DDx)

Medical DDx

Rule out medical causes such as the following:

Substance/medication-induced bipolar disorder
Recreational drugs
- Amphetamines, cocaine, hallucinogens, opiates, alcohol
Medications causing mania:
- Antihypertensives – Captopril
- Neurologic – Levodopa, D2 agonists (Pramipexole)
- Endocrine– Estrogens, testosterone, glucocorticoids, ACTH, thyroid hormones
- Antibiotics -- Fluoroquinolones (Ciprofloxacin)
Neurologic conditions, e.g. Head trauma
Thyroid problems

Psychiatric DDx

Major depressive disorder
Bipolar I Disorder
Bipolar II Disorder
Cyclothymia
Generalized anxiety disorder, panic disorder, posttraumatic stress disorder, or other anxiety disorders
Attention-deficit/hyperactivity disorder
Personality disorders

Comorbidity

High rates of comorbid conditions, such as
- Alcohol and substance abuse
- Anxiety disorders
- Personality disorders

Investigations

There are no diagnostic tests for bipolar disorder, however, consider the following to rule out contributory medical conditions:

CBC - Pernicious anemia
Fasting glucose level, lipid profile - Diabetes mellitus, hyperlipidemia, Cushing syndrome)
Liver function tests - hepatitis
TSH level - thyroid disorders
Urinalysis - infection in older patients
Urine toxicology - substance abuse
With new-onset psychosis, consider investigations to rule out seizure disorder, intracranial mass, and other causes of secondary psychosis such as:
- EEG
- MRI or CT

In the event that medications will be started, CANMAT guidelines recommend the following baseline indices (CANMAT, 2010)

CBC – baseline for anticonvulsants
Electrolytes
Fasting glucose - baseline for any medication that may cause weight gain or hyperglycemia
Fasting lipid profile (TC, VLDL, LDL, HDL, TG) - baseline for any medication that may cause weight gain or hyperglycemia
Liver enzymes – baseline for anticonvulsants and antipsychotics
Serum bilirubin
Platelets, Prothrombin time and partial thromboplastin time
Urinalysis
Urine toxicology for substance use
Serum creatinine
24-h creatinine clearance (if there is a history of renal disease)
Thyroid-stimulating hormone (TSH) – baseline for lithium
Electrocardiogram (ECG) (>40 years or if indicated) – baseline for medications like lithium and antipsychotics that can prolog QTc interval
Pregnancy test in females (if positive, teratogenic medications would be avoided)
Prolactin (baseline)

Physical exam

Baseline monitoring (in the event medications are started for bipolar)
- Body mass index (height, weight)
- Blood pressure
- Waist circumference
Neurological evaluation
- Monitor for medication adverse effects such as extrapyramidal effects (if on antipsychotics), tremors / cerebellar symptoms (if on lithium)

Management: When and Where to Refer

Is the patient acutely manic? Are there concerns about self-harm or inability to care for oneself? Is there a risk of financial self-harm (e.g. spending excessively)? Is there a risk of employment harm (e.g. going to work in a hypomanic/manic state)?

If so, then consider acute hospitalization via referral to an Emergency Department
See if there is a family member able to transport the patient otherwise contact Emergency Medical Services (e.g. 911 for an ambulance transfer)

Is the patient somewhat unwell (such as beginning signs of mania or hypomania) but not so severe enough to require hospitalization?

Consider urgent follow-up options through mental health services
Consider starting medication such as a sedating antipsychotic (with mood-stabilizing properties) to hopefully stabilize sleep/wake cycles until the patient can be seen soon
Options include
- Olanzapine (Zyprexa)
  - Start at 5-10 mg /day
  - Target 5-20 mg/day
  - Max daily dosage is 20 mg/day
- Resperidone (Risperdal)
  - Start at 1-2 mg daily, given once or twice daily
  - Target dose 4-6 mg daily
  - Max 8 mg daily
- Quetiapine (Seroquel)
  - Start at 100 mg daily
  - Target to 300-800 mg / daily for depression
  - Max daily dosage 600 mg daily
- Aripiprazole (Abilify)
  - Start at 15 mg/day
  - Target to 15-30 mg daily
  - Max daily dosage = 30 mg daily

Is the patient stable, however the presentation is complex, with unclear diagnosis?

Consider referral to outpatient mental health services for diagnostic clarification and treatment recommendations

Is the patient stable, with a known diagnosis of bipolar?

Monitor any signs that might indicate a need for hospitalization.
Monitor medications and case management.
If the patient would benefit from counselling/psychotherapy, then consider referral for counselling/psychotherapy.

Office Counseling for bipolar

Lifestyle Changes
- Stop any stimulants (e.g. caffeine, nicotine), alcohol, nicotine, and recreational drugs
- Regular exercise
- Go to bed regularly at the same time on weekdays and weekends (as opposed to staying up later on weekends)
- Have a well-balanced diet
  - Omega 3 fatty acids may possibly be helpful in addition to medications, but are not a replacement for medication (Balanza-Martinez, 2011.)
Coping and action plans
- Help the patient develop an action which includes
- What are the signs that I am well?
- What are the signs I am having a relapse?
- What are my triggers?
- What can I do about it? What are healthy ways I can cope with stress in general?
Positive mental health strategies
- Help the patient live a meaningful life with meaningful activities and relationships (Frankl, 1946; Fredrickson, 2013)
- For example:
  - Altruism: Helping others and making a contribution to the lives of others (as opposed to focusing on just oneself)
  - Nature: Spending time outside in nature (as opposed to spending time indoors, in artificial urban environments)
  - Practicing gratitude: Making a conscious effort to be grateful for what one has (as opposed to obsessing over what one doesn’t have)
Self-monitoring using Mood Charts
- Ask patients to chart their moods to assist with diagnosis and monitoring
- Patients assess their mood morning and night
- Mood charts are available freely online such as:
  - http://www.blackdoginstitute.org.au/docs/12.MoodChartforBipolarDisorder.pdf
  - http://www.cqaimh.org/pdf/tool_edu_moodchart.pdf

Types of Counseling / Therapy

Mental health professionals may provide different treatments, such as:

Psychoeducation
Cognitive behaviour therapy (CBT)
Interpersonal psychotherapy (IPT)
Interpersonal and social rhythm therapy (IPSRT)
Family focused therapy

More...

Medications for Bipolar I Disorder

Medications for acute management are often started by psychiatry when patients are acutely ill, but family physicians may also be starting bipolar medications as well.

Classic options were lithium and Divalproex, but nowadays, atypical antipsychotics can easily be started if necessary and without the need to monitor serum levels

Family physicians continue to be involved with ongoing monitoring when patients are stable on their bipolar medications

Acute Management of Manic Episode: First Line

Lithium

Start at 900 mg daily

Check serum level after 3-4 days and adjust

Target dose to 900-2400 mg daily

Max 3600 mg daily

Divalproex (Valproate)

Start at 500-1000 mg daily, given twice daily or at night

Increase by 500 mg/day every 1-2 weeks

Target 750-2000 mg daily

Max 60 mg /daily

Resperidone (Risperdal)

Start at 1-2 mg daily, given once or twice daily

Target dose 4-6 mg daily

Max 8 mg daily

Olanzapine (Zyprexa)

Start at 5-10 mg /day

Target 5-20 mg/day

Max daily dosage is 20 mg/day

Quetiapine (Seroquel)

Start at 100 mg daily

Target to 300-800 mg / daily for depression

Max daily dosage 800 mg daily

Aripiprazole (Abilify)

Start at 15 mg/day

Target to 15-30 mg daily

Max daily dosage = 30/day

* Note that doses for medications in manic phases may be higher than in maintenance therapy

For additional medication information, please see CANMAT Guidelines; Texas Medication Algorithm for Bipolar Disorder (TMABD); Lexi-Comp.

Maintenance therapy for Bipolar I Disorder

First Line

Lithium

Start and titrate up to 300 mg twice daily

Target dosage: Titrate every 1 to 5 days up to 900-1800 mg daily

Target serum level: 0.8-1.2 mmol/L

Lamotrigine (Lamictal)

Start 25 mg daily

Target dose: Slowly increase over 6 weeks to 200 mg daily

Divalproex (Valproate)

Start 500-750 mg daily

Target to 1000-3000 mg daily (administered twice daily);

Target serum level: 400-700 mmol/L

Olanzapine (Zyprexa)

Start 10-15 mg daily

Target dose 10-30 mg daily

Quetiapine (Seroquel)

Start 100-200 mg daily

Target dose 400-800 mg at bedtime

Risperidone (Risperdal)

Start 1-2 mg daily

Target dose 4-8 mg daily (usually given morning and bedtime)

Aripiprazole (Abilify)

Start 10-30 mg once daily

Target dose 15-30 mg once daily

Reference: CANMAT, 2010

Acute Management of Bipolar I depression

First-line monotherapy options

Lamotrigine	Without concomitant valproate Start weeks 1 and 2: 25 mg once daily; Weeks 3 and 4: 50 mg once daily; Week 5: 100 mg once daily; Week 6: 200 mg once daily Target: 200 mg daily With concomitant valproate Start: Weeks 1 and 2: 25 mg every other day; Weeks 3 and 4: 25 mg once daily; Week 5: 50 mg once daily; Week 6: 100 mg once daily Target: 100 mg daily With concomitant carbamazepine, phenytoin, phenobarbital, primidone, rifampin, or lopinavir/ritonavir, and without valproic acid: Start: Weeks 1 and 2: 50 mg once daily; Weeks 3 and 4: 100 mg daily in divided doses; Week 5: 200 mg daily in divided doses; Week 6: 300 mg daily in divided doses Target: 400 mg daily in divided doses
Quetiapine	Start 50 mg once daily at bedtime on day 1; increase to 100 mg once daily on day 2; further increase by 100 mg daily each day until 300 mg once daily is reached by day 4. Target dose: 300 mg once daily Maximum dose: 300 mg once daily.
Quetiapine XR	Start 50 mg once daily on day 1; increase to 100 mg once daily on day 2, further increase by 100 mg once daily until 300 mg once daily is reached by day 4. Target dose: 300 mg once daily Maximum dose: 300 mg once daily (US labelling) or 600 mg once daily (Canadian labelling).
Lithium	Start 300 mg to 300 mg po bid Check Li level (12 hours after the last dose) after 5-7 days Increase gradually in 300 mg increments, targeting a blood level of 0.8-1.2 as tolerated.
Lurasidone	Start 20 mg daily, increase up to 120 mg/daily.

More...

Medications for Bipolar II Disorder

More...

Maintenance therapy of Bipolar II Disorder: CANMAT

First line

Lithium
Lamotrigine
Quetiapine

More...

Reference: Medication Charts

Mood stabilizers Used in Bipolar Disorder

Medication	Dosage	Monitoring
Divalproex (Valproate)	Start at 500-1000 mg/day Titrate by 500 mg/day every 1-2 weeks Target dose 750-2000 mg/daily	Baseline Weight CBC with differential Liver function tests (LFTS), e.g. AST, ALT, ALK) Coagulation tests Ongoing investigations Every 3-months for the first year, then once yearly Weight CBC LFTs Menstrual changes On history, monitor for any liver problems (e.g. bleeding problems, jaundice) Divalproex serum levels: Therapeutic range 400-700 mmol/L Obtain 3-5 days after the most recent dose titration Establish 2 consecutive serum levels in the therapeutic range during acute phase
Lithium	Start at 300 mg po bid (with elderly, start at lower doses such as 150 mg po bid) Adjust by 300-600 mg increments Target dose usually 900 to 1,800 mg daily in divided doses.	Baseline investigations Weight TSH Renal function (BUN/Cr) Calcium Ongoing investigations Lithium level every 3-6 months Renal function (BUN/Cr) every 3-6 months TSH, weight, calcium every 6-months Lithium serum levels: Check serum level 5-7 days after the most recent dose titration (12 hours after the last dose, i.e. trough level) Target blood level 0.6-0.8 mmol/L for maintenance; above > 1.2 mmol is potentially toxic Establish 2 consecutive serum levels in the therapeutic range during acute phase
Carbamazepine	Start at 400 mg/day in 2 divided doses (oral) or 4 divided doses (oral suspension) May adjust by 200 mg/day increments; Maximum dose: 1600 mg/day.	Baseline Monthly for the first 3 months CBC Liver function tests (LFTS), e.g. AST, ALT, ALK) Electrolytes Urea / Creatinine Ongoing monitoring Once yearly CBC Liver function tests (LFTS), e.g. AST, ALT, ALK) Electrolytes Urea / Creatinine At least 2 drug serum levels in initiation phase of treatment and then every 3 to 6 months or with dosing changes

Atypical Antipsychotics Used in Bipolar Disorder

Medication	Dosage
Olanzapine (Zyprexa)	Start 5-10 mg daily Target 10-20 mg daily
Risperidone (Risperdal)	Start 1-2 mg daily Target 2-3 mg daily
Quetiapine (Seroquel)	Start 50 mg bid Target 300-600 mg daily
Quetiapine XR (Seroquel XR)	Start 50 mg at supper Target 300-600 mg daily
Aripiprazole (Abilify)	Start 5-10 mg daily Target 15-30 mg daily

Monitoring

View CAMESA Guidelines for more detailed monitoring information for antipsychotics
http://camesaguideline.org/information-for-doctors

Clinical algorithms

Texas Implementation of Medication Algorithms (TIMA) for Bipolar
http://www.medscape.org/viewarticle/524957

Clinical Practice Guidelines

Yatham LN, Kennedy SH, Parikh SV, et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) collaborative update of CANMAT guideline for the management of patients with bipolar disorder: update 2013. Bipolar Disorders 2013: 15: 1-44.
http://canmat.org/resources/CANMAT%20Bipolar%20Disorder%20Guidelines%20-2013%20Update.pdf
Practice Guideline for the Treatment of Patients with Bipolar Disorder: Second Edition. American Psychiatric Association, 2002.
http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/bipolar.pdf

References

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: Fifth Edition (DSM-5), 2013.
Canmat.org. Bipolar Disorder: Epidemiology of bipolar disorder - Provided by CANMAT [Internet]. 2015 [cited 9 June 2015]. Available from: http://www.canmat.org/di-bipolar-epidemiology.php
Culpepper L. The role of primary care clinicians in diagnosing and treating bipolar disorder. Prim Care Companion J Clin Psychiatry. 2010; 12(suppl 1): 4-9.
Culpepper L. The diagnosis and treatment of bipolar disorder: Decision-making in primary care. Prim Care Companion CNS Disord. 2014; 16(3).
Frankl V. Man's Search for Meaning: An Introduction to Logotherapy, 1946.
Fredrickson et al.: A functional genomic perspective on human well-being, Proceedings of the National Academy of Sciences of the United States of America (PNAS). 2013; 110(33): 13684–13689, doi: 10.1073/pnas.1305419110
Retrieved July 18, 2015 from http://www.pnas.org/content/110/33/13684.abstract
Goldbloomd DS, Davine J. Psychiatry in Primary Care: A COncise Canadian Pocket Guide, 2011.
Kaye N. A primary care approach to bipolar disorder. Johns Hopkins Advanced Studies in Medicine. 2006; 6(6A): S442-S458.
Lau, T. Differential Diagnosis of Mood Disorders. Jan 2015 [Powerpoint Slides].
Petit L. Diagnostique différentiel des troubles de l’humeur. Jan 2015 [Powerpoint Slides].
Price AL, Marzani-Nissen GR. Bipolar Disorders: A Review. Am Fam Physician. 2012; 85(5):483-493.
Stovall J, Keck P, Solomon D. Bipolar disorder in adults: Pharmacotherapy for acute mania and hypomania. In: UpToDate (Accessed June 11, 2015)

About this Document

Written by Talia Abecassis (uOttawa Medical Student, Class of 2017) and Dr. Doug Green (Psychiatrist, Ottawa Hospital). Reviewed by members of the eMentalHealth.ca Primary Care Team, including Dr’s M. St-Jean (family physician), E. Wooltorton (family physician), F. Motamedi (family physician), M. Cheng (psychiatrist).

Disclaimer

Information in this pamphlet is offered ‘as is' and is meant only to provide general information that supplements, but does not replace the information from a health professional. Always contact a qualified health professional for further information in your specific situation or circumstance.

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You are free to copy and distribute this material in its entirety as long as 1) this material is not used in any way that suggests we endorse you or your use of the material, 2) this material is not used for commercial purposes (non-commercial), 3) this material is not altered in any way (no derivative works). View full license at http://creativecommons.org/licenses/by-nc-nd/2.5/ca/

Related Info Sheets

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Bipolar Disorder in Children/Youth: Information for Primary Care

Bipolar Disorder in Children/Youth: Information for Psychiatry Residents

Medication Table: Bipolar Medications (Mood Stabilizers)

Date Posted: Jul 20, 2015
Date of Last Revision: May 16, 2024

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Bipolar Disorders

Table of Contents

Case of Hypomania: “She vacuums in the middle in the middle of the night”

Case of Mania: “I’m scared of my husband... He's not himself..."

Epidemiology

Screening

Screening Tools

History / Screening Questions

Diagnosis (Dx)

Main Bipolar Disorders

DSM-5 Bipolar Disorders

Differential Diagnosis (DDx)

Comorbidity

Investigations

Physical exam

Management: When and Where to Refer

Office Counseling for bipolar

Types of Counseling / Therapy

Medications for Bipolar I Disorder

Medications for Bipolar II Disorder

Reference: Medication Charts

Clinical algorithms

Clinical Practice Guidelines

References

About this Document

Disclaimer

Creative Commons License

Related Info Sheets

Bipolar Disorder in Adults

Bipolar Disorder in Children and Youth: Information for Families

Bipolar Disorder in Children/Youth: Information for Primary Care

Bipolar Disorder in Children/Youth: Information for Psychiatry Residents

Medication Table: Bipolar Medications (Mood Stabilizers)

Patient Handouts

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Bipolar Disorder in Adults

Introduction Ever since his mid 20's, a normally shy man gets high energy periods lasting up to several days where he doesn't need to sleep, and where he impulsively goes on spending sprees that put him into severe debt. These high periods are often followed by periods of severe low mood and depression, even to the point where he has thoughts of suicide. What's going on here? Is it normal mood swings, or could it be something else? What Is Bipolar Disorder? Everyone gets mood swings whereby sometimes our mood and energy is up, and where sometimes our mood and energy is down. But if you have mood swings so severe that it ...

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Bipolar Disorder in Children and Youth: Information for Families

What Is Bipolar Disorder? All of us have changes and swings in our mood which are normal. There are times when our mood is up, and we have more energy and excitement about things. There are other times when our moods are down, and we have less energy. However, people with bipolar disorder have periods of extreme mood change that cause serious problems in their lives. In the classic form of bipolar, people have episodes of depression and of mania, when their mood, energy, thinking and behaviour gets stuck for a period of time at a very low or a very high level. Hence the term, "bipolar", ...

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Bipolar Disorder in Children/Youth: Information for Primary Care

Case 15-yo Fernando is brought by his parents for problems with unstable moods. He was previously seen with depressed mood and started on an SSRI trial. Unfortunately, the trial led to a period of worsening characterized by decreased need for sleep, euphoric moods, increased activities (e.g. praying for several hours a day including late at night) and talking non-stop. Afterwards, it was followed by a depressive episode where he was feeling suicidal. His parents ask: “Do we need to increase the dose of his antidepressant?” Epidemiology Bipolar often starts in childhood and young adulthood Up ...

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Bipolar Disorder in Children/Youth: Information for Psychiatry Residents

Case 15-yo Dave is referred to see you by his family physician for unstable moods. He was previously seen with depressed mood and started on an SSRI trial. Unfortunately, the trial led to a period of worsening characterized by decreased need for sleep, euphoric moods, increased activities (e.g. increased religiosity with saying prayers, working out in the middle of the night) and talking non-stop. Afterwards, it was followed by a depressive episode where he was feeling suicidal. His parents ask: “Do we need to increase the dose of his antidepressant?” Epidemiology Bipolar often starts in childhood and young adulthood Up to 2/3 of ...

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Medication Table: Bipolar Medications (Mood Stabilizers)

Mood Stabilizers Medication Forms Dose (Start, Initial Target, Max) Comments Lamotrigine (Lamictal) Tablets 25, 100,150, 200 mg Adolescent/adults: Week 1,2: 25 mg morn Week 3,4: 50 mg morn Week 5: 50 mg morn + 50 mg qhs Week 6: 75 mg morn + 75 mg qhs Week 7: 100 mg morn + 100 mg qhs Usual target range is 225-375 mg daily, in two divided dosages. Side effects: nausea (7-14%) Warnings: Stop immediately if rash is seen (including Stevens Johnson syndrome with mouth ulcers). Higher risk if taking adjunctive ...

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What medications are used to treat bipolar disorder? Bipolar disorder, also called manic-depressive illness, is commonly treated with mood stabilizers. Sometimes, antipsychotics and antidepressants are used along with a mood stabilizer. Mood stabilizers People with bipolar disorder usually try mood stabilizers first. In general, people continue treat...

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What medications are used to treat bipolar disorder?

Bipolar disorder, also called manic-depressive illness, is commonly treated with mood stabilizers. Sometimes, antipsychotics and antidepressants are used along with a mood stabilizer.

Mood stabilizers

People with bipolar disorder usually try mood stabilizers first. In general, people continue treatment with mood stabilizers for years. Lithium is a very effective mood stabilizer. It was the first mood stabilizer approved by the FDA in the 1970's for treating both manic and depressive episodes.

Anticonvulsant medications also are used as mood stabilizers. They were originally developed to treat seizures, but they were found to help control moods as well. One anticonvulsant commonly used as a mood stabilizer is valproic acid, also called divalproex sodium (Depakote). For some people, it may work better than lithium.6 Other anticonvulsants used as mood stabilizers are carbamazepine (Tegretol), lamotrigine (Lamictal) and oxcarbazepine (Trileptal).

Atypical antipsychotics

Atypical antipsychotic medications are sometimes used to treat symptoms of bipolar disorder. Often, antipsychotics are used along with other medications.

Antipsychotics used to treat people with bipolar disorder include:

Olanzapine (Zyprexa), which helps people with severe or psychotic depression, which often is accompanied by a break with reality, hallucinations, or delusions7
Aripiprazole (Abilify), which can be taken as a pill or as a shot
Risperidone (Risperdal)
Ziprasidone (Geodon)
Clozapine (Clorazil), which is often used for people who do not respond to lithium or anticonvulsants.8

Antidepressants

Antidepressants are sometimes used to treat symptoms of depression in bipolar disorder. Fluoxetine (Prozac), paroxetine (Paxil), or sertraline (Zoloft) are a few that are used. However, people with bipolar disorder should not take an antidepressant on its own. Doing so can cause the person to rapidly switch from depression to mania, which can be dangerous.9 To prevent this problem, doctors give patients a mood stabilizer or an antipsychotic along with an antidepressant.

Research on whether antidepressants help people with bipolar depression is mixed. An NIMH-funded study found that antidepressants were no more effective than a placebo to help treat depression in people with bipolar disorder. The people were taking mood stabilizers along with the antidepressants. You can find out more about this study, called STEP-BD (Systematic Treatment Enhancement Program for Bipolar Disorder), here.10

What are the side effects?

Treatments for bipolar disorder have improved over the last 10 years. But everyone responds differently to medications. If you have any side effects, tell your doctor right away. He or she may change the dose or prescribe a different medication.

Different medications for treating bipolar disorder may cause different side effects. Some medications used for treating bipolar disorder have been linked to unique and serious symptoms, which are described below.

Lithium can cause several side effects, and some of them may become serious. They include:

Loss of coordination
Excessive thirst
Frequent urination
Blackouts
Seizures
Slurred speech
Fast, slow, irregular, or pounding heartbeat
Hallucinations (seeing things or hearing voices that do not exist)
Changes in vision
Itching, rash
Swelling of the eyes, face, lips, tongue, throat, hands, feet, ankles, or lower legs.

If a person with bipolar disorder is being treated with lithium, he or she should visit the doctor regularly to check the levels of lithium in the blood, and make sure the kidneys and the thyroid are working normally.

Some possible side effects linked with valproic acid/divalproex sodium include:

Changes in weight
Nausea
Stomach pain
Vomiting
Anorexia
Loss of appetite.

Valproic acid may cause damage to the liver or pancreas, so people taking it should see their doctors regularly.

Valproic acid may affect young girls and women in unique ways. Sometimes, valproic acid may increase testosterone (a male hormone) levels in teenage girls and lead to a condition called polycystic ovarian syndrome (PCOS).11,12 PCOS is a disease that can affect fertility and make the menstrual cycle become irregular, but symptoms tend to go away after valproic acid is stopped.13 It also may cause birth defects in women who are pregnant.

Lamotrigine can cause a rare but serious skin rash that needs to be treated in a hospital. In some cases, this rash can cause permanent disability or be life-threatening.

In addition, valproic acid, lamotrigine, carbamazepine, oxcarbazepine and other anticonvulsant medications (listed in the chart at the end of this document) have an FDA warning. The warning states that their use may increase the risk of suicidal thoughts and behaviors. People taking anticonvulsant medications for bipolar or other illnesses should be closely monitored for new or worsening symptoms of depression, suicidal thoughts or behavior, or any unusual changes in mood or behavior. People taking these medications should not make any changes without talking to their health care professional.

Other medications for bipolar disorder may also be linked with rare but serious side effects. Always talk with the doctor or pharmacist about any potential side effects before taking the medication.

For information on side effects of antipsychotics, see the section on medications for treating schizophrenia.

For information on side effects and FDA warnings of antidepressants, see the section on medications for treating depression.

How should medications for bipolar disorder be taken?

Medications should be taken as directed by a doctor. Sometimes a person's treatment plan needs to be changed. When changes in medicine are needed, the doctor will guide the change. A person should never stop taking a medication without asking a doctor for help.

There is no cure for bipolar disorder, but treatment works for many people. Treatment works best when it is continuous, rather than on and off. However, mood changes can happen even when there are no breaks in treatment. Patients should be open with their doctors about treatment. Talking about how treatment is working can help it be more effective.

It may be helpful for people or their family members to keep a daily chart of mood symptoms, treatments, sleep patterns, and life events. This chart can help patients and doctors track the illness. Doctors can use the chart to treat the illness most effectively.

Because medications for bipolar disorder can have serious side effects, it is important for anyone taking them to see the doctor regularly to check for possibly dangerous changes in the body.

Reprints:

This publication is in the public domain and may be reproduced or copied without permission from NIMH. We encourage you to reproduce it and use it in your efforts to improve public health. Citation of the National Institute of Mental Health as a source is appreciated. However, using government materials inappropriately can raise legal or ethical concerns, so we ask you to use these guidelines:

NIMH does not endorse or recommend any commercial products, processes, or services, and our publications may not be used for advertising or endorsement purposes.
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U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
National Institutes of Health
NIH Publication No. 08-3929
Revised 2008

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Counseling can help children with bipolar disorder, and everyone around them, to understand that their symptoms reflect a biological illness with complex genetic and environmental origins--not personality or an oppositional attitude. Counseling also can reduce the impact of symptoms on daily life. A variety of psychological interventions can be helpful, and parents should discuss their child...

More...

Individual psychotherapy may be useful for young people with bipolar disorder, particularly when there are ongoing stressors in their lives that make symptoms worse. Children with the disorder often carry a sense of failure, as if the illness was their fault. In many cases, they are aware that when they are unable to control their behavior, they may hurt people closest to them, which can increase their sense of self-blame. Individual psychotherapy can help young people become aware of and address these feelings.
Cognitive Behavior Therapy (CBT) helps a child or adolescent to become aware of, and to describe, negative thoughts, feelings or reactions. A trained clinician guides the child to think of new, more positive alternatives. The young person is then given a chance to practice new thoughts, feelings, or reactions outside the clinical visit, and to discuss his or her experiences with the clinician afterwards. These methods are based upon practices that have helped many children and adolescents.
Parent guidance sessions can help parents to manage their child's illness, identify effective parenting skills, learn how to function as a family despite the illness, and to address complex feelings that can arise when raising a child with a psychiatric disorder. Family therapy may be beneficial when issues are affecting the family as a whole.
Group psychotherapy can be valuable to a child by providing a safe place to talk with other children who face adversity or allowing a child to practice social skills or symptom-combating skills in a carefully structured setting
School-based counseling can be effective in helping a child with bipolar disorder navigate the social, behavioral, and academic demands of the school setting

Special thanks to Dr. Bostic and the School Psychiatry Program at Massachusetts General Hospital for permission to reproduce these recommendations.

For more information, visit www.schoolpsychiatry.org.

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Examples of Common Workplace Accommodations Accommodations should be based on your needs and the employer’s resources. There is no standard list of reasonable accommodations, but here is a list of commonly provided workplace accommodations: Job coach assistance in hiring and on the job mentoring as necessary. Job coach/mentor could be from an external agency or be f...

More...

Examples of Common Workplace Accommodations

Accommodations should be based on your needs and the employer’s resources. There is no standard list of reasonable accommodations, but here is a list of commonly provided workplace accommodations:

Job coach assistance in hiring and on the job mentoring as necessary. Job coach/mentor could be from an external agency or be from within the organization.

Flexible scheduling to accommodate effects of medications, time for appointments, more frequent breaks, switch to temporary part-time hours without fear of losing job.

Changes in supervision, for example how feedback and instruction are given, or having weekly supervision appointments to check in and prevent problems before they can happen.

In training, allowing more time for tasks to be learned, or allowing for individualized, one-on-one training.

Appropriate technology like a tape recorder to tape instructions, head phones to block out loud noise, etc.

Modifying work space or changing location so it is quieter, fewer distractions; allowing an employee to work at home.

Allowing an employee to exchange minor job tasks with others.

Rights and Responsibilities of the Employer & Employee

The Employer Should:

Create and maintain an atmosphere where people feel comfortable asking for accommodation, including providing information about the organization’s policies and creating ways for requests to happen confidentially.

Assume that the employee’s request for accommodation is made in good faith.

In a timely manner, work with the employee (and a professional, if necessary), to explore all options for accommodation.

Maintain records of the request and steps taken to deal with the request.

Maintain and respect confidentiality issues.

Pay the cost of the accommodations, including fees for any medical certificates required.

Request only information that is directly related to developing an appropriate accommodation.

Ensure that managers and supervisory staff will not tolerate any discrimination or harassment as a result of an illness or an accommodation.

The Employee Should

Tell the employer you need an accommodation, due to a disability, and give them the information they need to understand what the limitations are and what accommodations would address them.

If requested, provide supporting documentation or medical certificates.

Meet all relevant job requirements and standards once the accommodation has been provided.

Continue to work with the employer to ensure that the accommodation remains effective and to check in with how you are doing.

SOURCE

Adapted from “Employment” , in “From Rollercoaster to Recovery”.

ADDITIONAL INFORMATION

The Alberta Human Rights Commission has additional information on responsibilities for employers around employees with addictions issues
http://www.albertahumanrights.ab.ca/publications/bulletins_sheets_booklets/ sheets/protected_grounds/drug_and_alcohol_dependencies.asp

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More...

Individual psychotherapy may be useful for young people with bipolar disorder, particularly when there are ongoing stressors in their lives that make symptoms worse. Children with the disorder often carry a sense of failure, as if the illness was their fault. In many cases, they are aware that when they are unable to control their behavior, they may hurt people closest to them, which can increase their sense of self-blame. Individual psychotherapy can help young people become aware of and address these feelings.
Cognitive Behavior Therapy (CBT) helps a child or adolescent to become aware of, and to describe, negative thoughts, feelings or reactions. A trained clinician guides the child to think of new, more positive alternatives. The young person is then given a chance to practice new thoughts, feelings, or reactions outside the clinical visit, and to discuss his or her experiences with the clinician afterwards. These methods are based upon practices that have helped many children and adolescents.
Parent guidance sessions can help parents to manage their child's illness, identify effective parenting skills, learn how to function as a family despite the illness, and to address complex feelings that can arise when raising a child with a psychiatric disorder. Family therapy may be beneficial when issues are affecting the family as a whole.
Group psychotherapy can be valuable to a child by providing a safe place to talk with other children who face adversity or allowing a child to practice social skills or symptom-combating skills in a carefully structured setting
School-based counseling can be effective in helping a child with bipolar disorder navigate the social, behavioral, and academic demands of the school setting

Special thanks to Dr. Bostic and the School Psychiatry Program at Massachusetts General Hospital for permission to reproduce these recommendations.

For more information, visit www.schoolpsychiatry.org.

Add to Info Cart

More...

Examples of Common Workplace Accommodations

Accommodations should be based on your needs and the employer’s resources. There is no standard list of reasonable accommodations, but here is a list of commonly provided workplace accommodations:

Job coach assistance in hiring and on the job mentoring as necessary. Job coach/mentor could be from an external agency or be from within the organization.

Flexible scheduling to accommodate effects of medications, time for appointments, more frequent breaks, switch to temporary part-time hours without fear of losing job.

Changes in supervision, for example how feedback and instruction are given, or having weekly supervision appointments to check in and prevent problems before they can happen.

In training, allowing more time for tasks to be learned, or allowing for individualized, one-on-one training.

Appropriate technology like a tape recorder to tape instructions, head phones to block out loud noise, etc.

Modifying work space or changing location so it is quieter, fewer distractions; allowing an employee to work at home.

Allowing an employee to exchange minor job tasks with others.

Rights and Responsibilities of the Employer & Employee

The Employer Should:

Create and maintain an atmosphere where people feel comfortable asking for accommodation, including providing information about the organization’s policies and creating ways for requests to happen confidentially.

Assume that the employee’s request for accommodation is made in good faith.

In a timely manner, work with the employee (and a professional, if necessary), to explore all options for accommodation.

Maintain records of the request and steps taken to deal with the request.

Maintain and respect confidentiality issues.

Pay the cost of the accommodations, including fees for any medical certificates required.

Request only information that is directly related to developing an appropriate accommodation.

Ensure that managers and supervisory staff will not tolerate any discrimination or harassment as a result of an illness or an accommodation.

The Employee Should

Tell the employer you need an accommodation, due to a disability, and give them the information they need to understand what the limitations are and what accommodations would address them.

If requested, provide supporting documentation or medical certificates.

Meet all relevant job requirements and standards once the accommodation has been provided.

Continue to work with the employer to ensure that the accommodation remains effective and to check in with how you are doing.

SOURCE

Adapted from “Employment” , in “From Rollercoaster to Recovery”.

ADDITIONAL INFORMATION

The Alberta Human Rights Commission has additional information on responsibilities for employers around employees with addictions issues
http://www.albertahumanrights.ab.ca/publications/bulletins_sheets_booklets/ sheets/protected_grounds/drug_and_alcohol_dependencies.asp

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Bipolar Disorder in Adults: Information for Primary Care

Case of Hypomania: “She vacuums in the middle in the middle of the night”

Case of Mania: “I’m scared of my husband... He's not himself..."

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