Last updated:
March 30, 2026
Table Of Contents
Bipolar Disorder
Bipolar disorder is characterized by recurrent mood disturbance mixed with mania/hypomania + depression. Thought to be a bridge between unipolar depression and Schizophrenia spectrum disorders. The genetic link in Bipolar disorder is stronger than that of Unipolar depression, but less than that of Schizophrenia.
Mania is more common in men than in women. Mixed episodes are more common in women. Rapid cycling is also more common in women (≥ 4 episodes per year). There is a high risk of relapse post-delivery in women of childbearing age. It is more common in individuals with a higher socio-economic status (SES).
25-50% of patients attempt suicide in the depressive phase. 15% complete suicide.
Classification of Bipolar Disorder
| Classification | Criteria |
|---|---|
| Bipolar I Disorder (Bipolar Depression) | At least one manic episode; may be accompanied by MDD |
| Bipolar II Disorder | MDD accompanied by a hypomanic episode |
| Cyclothymic Disorder | ≥ 2 years of alternating hypomania and dysthymia; ≥ 1 year in children and adolescents |
| Bipolar disorder due to substance or medication | Caused by chronic use of benzodiazepines and cannabis |
| Bipolar disorder due to another medical condition | Caused by neurosyphilis and HIV |
| Bipolar disorder not otherwise specified |
Bipolar I vs Bipolar II Disorder
| Bipolar I Disorder (BPID) | Bipolar II Disorder (BPIID) | |
|---|---|---|
| Presentation | A manic episode that causes a problem or danger | Depression with a history of hypomania |
| Frequency | Less common | More common |
| Men:women ratio | 1:1 | 1:1 |
| Genetic linkage | Very high | Very high |
Etiology
Biological Factors
| Biological factors | Description |
|---|---|
| Genetics | Strong genetic linkage (50-70% predisposition)BPIID > BPID > Unipolar depression |
| Endocrine | Increased hormones (Testosterone) in manic highs |
Psychological Factors
| Psychosocial factors | Description |
|---|---|
| Personality | Cluster B personality (Dramatic and Erratic) |
| Attachment theory or psychosocial theories | 90% develop in childhood but manifest in adulthood |
| Psychodynamic theory (Abraham, M. Kleine) | Mania is an unconscious defense against underlying depression |
| Bad events | Losses, trauma, childhood abuse, failed exams, etc., can precipitate depressive episodes |
| Good events | Winning the lottery, promotion, passing an exam, etc., can precipitate manic episodes |
| Relationships | Higher incidence in single (not by choice) than married |
| Socioeconomic status (SES) | Higher incidence in high SES than Low SES |
- What are patients with bipolar disorder at an increased risk of?
- Suicide and self-harm
- Financial risk
- Physical health risk: Diabetes mellitus, cardiovascular disease, sexually transmitted diseases, pregnancy
- Alcohol and drug abuse
- Driving and accidents
- Characteristics of depression in Bipolar Disorder
- Early age of onset (18 years old in BPID, mid-20s in BPIID)
- High chance of reversed vegetative symptoms (hypersomnia, increased appetite)
- Increased risk of relapse
- Higher familial genetic link
- More reactive to mood stabilizers and SSRIs
- Investigations
- Urine tox screen
- TFTs (Hyperthyroidism, Hypothyroidism)
- Adrenal function tests (Pheochromocytoma Hyperadrenalism)
- HIV/AIDS
- Viral (Rabies)
- RPR/VDRL (Syphilis)
- ANA (SLE)
- CBC (Acute blood loss)
- BS for MPS (cerebral malaria; watch out for false positives in endemic areas)
- Head CT (Non-dominant hemisphere stroke or tumor)
- EEG (Epilepsy)
- Metabolites of neurotransmitters in urine, serum, or CSF (Homovanillic acid, 5-IAA)
- Differentials
- Drugs (Cannabis, Benzos, Cocaine causing mania, Captopril for BPID)
- Hypothyroidism
- Personality disorder: Mania will be a single episode, while in personality disorders, it will be persistent.
- Psychotic disorder: Bizarre delusions will be protracted
- Non-dominant hemisphere stroke or tumors
- Pharmacological treatment
- For the acute episode, combining a mood stabilizer and an antipsychotic is associated with better outcomes
- For maintenance, monotherapy with either an antipsychotic or a mood stabilizer can be used
- Mood stabilizers
- Lithium: preferred in acute mania
- Valproic acid: preferred in acute mania and mixed phase
- Carbamazepine: preferred in rapid cycling and mixed phase
- Lamotrigine: preferred in depressive phase
- Topiramate
- Gabapentin
- Antipsychotics (olanzapine, quetiapine, risperidone): Psychotic features, and as Mood Stabilizers, as depot (long-acting injections)
- SSRIs (Fluoxetine): add if no response to mood stabilizers. Isolated use can push depressed patients to mania in both BPID and BPIID or precipitate rapid cycling.
- Typical antipsychotics (haloperidol, ziprasidone): for agitated patients
- Physical therapy
- ECT: for bipolar disorder that is refractory to therapy and acute mania
- Psychotherapy
- CBT
- Family therapy
- Interpersonal and Social Rhythm therapy (IPSRT)
- Psychoeducation
- Treatment of Bipolar in teenagers
- Lithium
- Aripiprazole (Aripitas)
- Specifiers for diagnosing bipolar disorder
- Severity
- Mild BPID/BPIID
- Moderate BPID/BPIID
- Severe BPID/BPIID
- Current or Recent episode:
- BPID, Manic phase
- BPIID, Hypomanic phase,
- BPID/BPIID Depressive phase,
- BPID/BPIID Mixed phase
- Other features
- BPD with Psychotic features
- BPD with Rapid cycling
- BPD with Peripartum onset
- BPD with a seasonal pattern
- BPD with Anxious distress
- BPD with Catatonia
- Severity
- Good prognostic factors
- Short duration of episodes
- Acute
- Late onset
- Poor prognostic factors
- Poor pre-morbid function
- Psychotic features
- Depressive
- Male sex
- Family History
- Comorbidities
- Suicidal
- Controlling Bipolar Disorder
- Medication daily
- Exercise daily
- A balanced diet at regular times
- Routine sleep and wake
- Avoid alcohol and drugs
- Counselling (to reduce stress at work/home)
- Limit caffeine/nicotine during mania
- Avoid travelling to different time zones
- Seek treatment immediately if there are symptoms of relapse
- Support groups
Cyclothymic Disorder
Cyclothymia is a chronic disorder with periods of mild depression (< 5 SIGE CAPS) + hypomania, which come and go over at least two years, lasting for more than 2 years. Think of it as a mild form of BPIID. Bouts of depression are not as bad and do not meet the criteria for major depressive disorder (MDD).
There is a 33% risk of developing BPID and BPIID. 0.4-1% prevalence.
- Differentials (the same as BPIID)
- Drugs: cannabis, Benzodiazepines, and Cocaine – all of which can cause mania
- Hypothyroidism
- Personality disorder: Mania will be a single episode, while in personality disorders, it will be persistent.
- Treatment
- Rule out thyroid disorder and drugs
- Patients usually respond to mood stabilizers