Bipolar I Criteria1 or more manic/ mixed episode | Elevated, expansive, or irritable mood, and increased goal-directed activity or energy lasting ≥1 week (any duration if hospitalized), present most of the day, nearly every day |
Bipolar II CriteriaNever had a full manic episode | At least 1 hypomanic episode and at least 1 major depressive episode | Distinct period of abnormally and persistently elevated, expansive, or irritable mood, and increased goal-directed activity or energy lasting ≥4 but <7 days, and clearly different from usual nondepressed mood, present most of the day, nearly every day | Not severe enough to cause marked impairment, not due to substance or medical condition, and no psychosis |
Bipolar I and II- 3 or more of the followingGrandiosity | Decreased sleep | Pressured speech | Racing thoughts | Distractibility | Increased activity | Excessive pleasurable activities/ risk taking |
4 required if irritable mood only | | Mania Sx- GIDDINESSGrandiose | Increased activity | Decreased judgment and sleep | Delusional | Irritable | Non- attentive | Elevated mood and euphoria | Speedy speech | Speedy thoughts |
Demographics0.7% population at risk | 2.3 million adults | Age of onset in 20s normally | = in males and females |
Treatment GuidelinesTreat to remission regardless of the number of medications | Mood stabilizer or mood stabilizer + SGA | Discontinue antidepressants | Relapse risk is highest in first few months after treatment initiation | Lithium gold standard- but less effective in rapid cycling and mixed episodes |
MedsLithium | Depakote | Tegretol | Lamictal | SGAs (acute mania or psychosis) |
| | LithiumNormal level 0.5- 1.2 in acute phase | Normal level 0.6- 1.0 in maintenance phase | Dose 1,200- 2,400mg in acute phase; 900- 1,200mg in maintenance phase | SEs: weight gain, fine hand tremors, nausea, increased urination, thirst | Interactions: ACEs. ARBs, diuretics, NSAIDs, Topamax | Increase water intake | Antisuicidal properties | Toxicity: confusion, slurred speech, coarse hand tremors, severe GI effects | Avoid in pregnancy (especially 1st trimester) | Monitor KIDNEYS |
DepakoteNormal level 50-125 | Dosage 15- 50 mg/kg/ day | SEs: nausea diarrhea, abd cramps, sedation tremor, alopecia, liver issues | Rare: Stevens Johnson | Avoid in pregnancy | Interactions: Topamax (increased ammonium), tegretol (decreases levels of both drugs) | Increases levels of lamictal and SGAs | Monitor LIVER |
TegretolNormal level 6- 12 | Dose 10- 20 mg/kg/ day | SEs: nausea, dizziness, sedation, headaches, dry mouth, constipation, skin rash, liver issues | Rare: agranulocytosis/ aplastic anemia, Stevens- Johnson (In asians especially due to HLA-B 1502 allele) | Avoid in pregnancy | Monitor LIVER |
LamictalNo level | Dosage 25- 600mg/ day | SEs: dizziness, ataxia, somnolence, diplopia, nausea, headache liver issues | Rares: Stevens- Johnson | Maintenance only | Helps in depressive phases | Titrate super slow- 25mg q day x 2 weeks, then 50mg q day x 2 weeks etc | When added to depakote, lamictal level doubles | When added to tegretol, it is metabolized quicker | Often added to Lithium, SGAs or antidepressants |
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