Bipolar Affective Disorder & Mania

Recurrent illness with episodes of mania and/or depression. Strong hereditary basis; peak age of onset is early adult life.

• Bipolar I — at least one manic episode, with or without depressive episodes.
• Bipolar II — depressive episodes plus at least one hypomanic episode.

Diagnosis

Mania (DSM-5):

A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week.

B. Three or more of: inflated self-esteem/grandiosity; decreased need for sleep; increased talkativeness/pressured speech; racing thoughts/flight of ideas; distractibility; increased goal-directed activity; excessive activity with painful consequences.

C. Marked impairment in social/occupational functioning, or need for hospitalisation, or psychotic features.

D. Not attributable to a substance or another medical condition.

Hypomania only needs to last 4 days, doesn’t cause significant functional impairment, and doesn’t have psychotic features.

Presentation: symptoms of mania usually appear abruptly, often precipitated by stress, typically first in the teens or young adulthood. Typical features: reckless behaviour, overspending, hasty decisions, impaired judgement, poor insight, increased sexual drive/energy/activity, and variable psychotic symptoms (paranoia, grandiose delusions, auditory hallucinations).

Management: acute mania

A medical emergency — usually requires hospitalisation to protect the patient and/or family.

Antipsychotics are most effective for acute symptom control, particularly olanzapine, risperidone, and haloperidol.

• First-line: olanzapine 10–15 mg daily, titrated to response and tolerability (max 30 mg); or risperidone 2 mg daily, titrated in increments of 1 mg every few days (max 6 mg).
• Second-line: other second-generation antipsychotics; haloperidol; lithium; sodium valproate; carbamazepine.
• Combination therapy: an antipsychotic plus lithium or valproate.

Lithium dosing: 500–1000 mg daily in 2–3 divided doses, or as a single night-time dose. Measure serum levels 5–7 days after a steady dose, taken 8–12 hours after the last dose. Target range for acute mania: 0.8–1.2 mmol/L. Titrate in increments of 250–500 mg up to 1000–2500 mg/day, guided by levels.

Valproate dosing: 200–400 mg twice daily initially, increasing every 2–3 days by 200–500 mg. Measure serum levels after 3 days at a steady dose. Most patients need 1–2 g daily (max 3 g); target serum concentration 660–875 micromol/L (94–125 mg/L).

Continuing treatment: after the first manic episode, continue treatment for 6–12 months to prevent relapse. If an antipsychotic was combined with lithium/valproate, it can often be withdrawn over a few months post-episode; some patients need long-term prophylaxis.

Prophylaxis

~90% of patients with acute mania have recurrences, and most also experience recurrent depressive episodes — so ongoing prophylaxis is usually needed. Consider it after 2 episodes, or after one particularly severe manic episode.

• Drug choice mirrors acute management. Lithium is the best-studied option (target 0.6–0.8 mmol/L for prophylaxis).
• Most second-generation antipsychotics can be used; only the depot formulation of risperidone has specific evidence for prophylactic use.
• Olanzapine and quetiapine may help prevent both depressive and manic relapse.
• Lamotrigine helps prevent depressive but not manic relapse.
• Carbamazepine and sodium valproate are often used but lack strong prophylactic evidence.
• Psychotherapy augments pharmacotherapy and is particularly useful for preventing depressive relapse.

Bipolar depression

~80% of depressive episodes in bipolar disorder have melancholic features; melancholic depression in a young person is a red flag for a future manic episode.

Difficult to manage because antidepressants can trigger a switch into mania — there’s controversy over the details, but antidepressant monotherapy should not be used.

Drugs with trial evidence for monotherapy: cariprazine, lamotrigine, lithium, lurasidone, olanzapine, and quetiapine.

If an antidepressant is used at all, it should only be in combination with one of cariprazine, lithium, lurasidone, olanzapine, quetiapine, or sodium valproate — to guard against manic switch — and ideally guided by a psychiatrist if there’s a history of rapid cycling, mixed features, antidepressant-induced mood elevation, or active substance use. Noradrenergic antidepressants (TCAs, SNRIs, MAOIs) carry a higher switch risk than SSRIs, so SSRIs are the preferred class if one is needed. Antidepressants are recommended to be withdrawn shortly after resolution of the depressive episode, though this isn’t always feasible if symptoms re-emerge on withdrawal.