Bipolar mood disorder

Bipolar Mood Disorder is a chronic, recurrent psychiatric illness characterized by alternating episodes of mania, hypomania, depression, or mixed affective states. The disorder follows an episodic and variable course throughout life and significantly affects emotional regulation, cognition, behaviour, and psychosocial functioning.

By definition, diagnosis requires the presence of at least one manic or hypomanic episode, either current or historical. Bipolar disorder is associated with substantial morbidity, impaired occupational functioning, relationship difficulties, increased medical comorbidity, and elevated suicide risk.

Epidemiology

• Lifetime prevalence: approximately 1–3%

• Equal prevalence among males and females

• Usual onset: late adolescence or early adulthood

• High recurrence rate (>70%)

• Suicide risk approximately 15–20 times higher than general population

Risk Factors

Genetic Factors

• Strong hereditary component

• First-degree relatives have increased risk

• Polygenic inheritance pattern

Neurobiological Factors

• Dysregulation of dopamine, serotonin, and glutamate pathways

• Circadian rhythm disturbances

• Structural and functional brain abnormalities

Psychological Factors

• Stress sensitivity

• Personality vulnerabilities

• Poor coping mechanisms

Environmental & Social Factors

• Psychosocial stressors

• Sleep deprivation

• Substance misuse

• Major life transitions

Pathophysiology

Bipolar disorder involves abnormalities in:

• Neurotransmitter regulation

• Intracellular signalling pathways

• Neuroplasticity mechanisms

• Hypothalamic–pituitary–adrenal (HPA) axis regulation

• Circadian rhythm control systems

These disturbances produce instability in mood regulation networks.

Clinical Types

• Bipolar I Disorder – Mania ± depression

• Bipolar II Disorder – Hypomania + major depression

• Cyclothymic Disorder

• Rapid cycling bipolar disorder (≥4 episodes/year)

Signs and Symptoms

Manic Episode

• Elevated or euphoric mood

• Irritability or aggression

• Increased energy/activity

• Reduced need for sleep

• Excessive talkativeness (pressured speech)

• Racing thoughts

• Distractibility

• Risk-taking behaviour

• Inflated self-esteem or grandiosity

• Religious or persecutory delusions

• Poor judgement

Hypomania

Similar to mania but:

• Less severe

• No marked functional impairment

• No psychosis

• No hospitalization required

Depressive Episode

• Persistent low mood

• Loss of interest

• Fatigue

• Sleep disturbance

• Appetite change

• Feelings of guilt or hopelessness

• Suicidal ideation

Mixed Episode

Simultaneous manic and depressive symptoms:

• Agitation with sadness

• Insomnia

• High suicide risk

Diagnostic Criteria

Mania (DSM-5 Based)

Abnormally elevated, expansive, or irritable mood lasting ≥1 week, plus ≥3 of:

• Increased activity or energy

• Decreased need for sleep

• Grandiosity

• Pressured speech

• Flight of ideas

• Distractibility

• Risky behaviour

AND:

• Marked functional impairment, psychosis, or hospitalization.

Differential Diagnosis

• Major depressive disorder

• Schizoaffective disorder

• Substance-induced mood disorder

• ADHD

• Personality disorders

• Thyrotoxicosis

• Drug intoxication

Investigations

Purpose

Exclude medical or substance-related causes and establish treatment safety.

Recommended Tests

• Full blood count

• Renal function tests

• Liver function tests

• Thyroid function tests

• Blood glucose

• Electrolytes

• Toxicology screening

• Pregnancy test (where applicable)

Monitoring Tests

• Lithium serum levels

• Valproate levels

• Renal and thyroid monitoring during therapy

Management

Management includes acute stabilization, relapse prevention, and psychosocial rehabilitation.

Non-Pharmacological Management

Acute Phase

• Hospitalisation during severe mania or suicide risk

• Environmental stimulation reduction

• Sleep restoration

Psychosocial Interventions

• Psychoeducation (patient and family)

• Cognitive Behavioural Therapy

• Family-focused therapy

• Interpersonal and social rhythm therapy

• Medication adherence counselling

Other Interventions

• Electroconvulsive Therapy (ECT) for:

  • Severe mania

  • Treatment resistance

  • Psychotic depression

  • Suicidal emergencies

Pharmacological Management

1. Management of Manic or Mixed Episodes

Mood Stabilizers (First-line)

Sodium Valproate

• 20 mg/kg/day PO in 2–3 divided doses

OR

Carbamazepine

• Start 600 mg/day

• Increase by 200 mg every 3 days

• Maximum 2000 mg/day

OR

Lithium Carbonate

• 400–1000 mg/day PO (single or divided dose)

• Elderly: start 400 mg/day

Adjunct Therapy

If agitation or psychosis present:

• Haloperidol + benzodiazepine may be added temporarily.

2. Maintenance Therapy

Goals:

• Prevent relapse

• Stabilize mood

• Improve functioning

Options:

• Lithium carbonate

• Sodium valproate

• Carbamazepine

Long-term therapy is usually lifelong.

3. Bipolar Depression

⚠ Antidepressant monotherapy is contraindicated

Treatment:

• Amitriptyline 50 mg nocteAND

• Carbamazepine 300 mg twice daily

Add:

• Haloperidol 3–4.5 mg every 12 hours if psychosis present.

Treatment Principles

• Initiate therapy gradually

• Monitor adherence closely

• Avoid abrupt discontinuation

• Monitor drug toxicity

• Maintain regular sleep patterns

Complications

• Suicide

• Substance abuse

• Psychosis

• Cognitive impairment

• Occupational dysfunction

• Relationship breakdown

• Medication toxicity

Special Populations

Pregnancy

• Avoid valproate when possible (teratogenic risk)

• Specialist psychiatric management required

Elderly

• Increased sensitivity to lithium toxicity

• Lower dosing recommended

Adolescents

• Often misdiagnosed initially as depression or ADHD

Prevention

• Long-term mood stabilizer therapy

• Early treatment of relapse symptoms

• Sleep regulation

• Stress reduction

• Substance avoidance

• Family education and support

• Regular psychiatric follow-up

Prognosis

• Lifelong condition with recurrent episodes

• Good outcomes achievable with adherence

• Relapse common if medication discontinued

• Early intervention improves functional recovery

Patient & Family Education

Patients and caregivers should understand:

• Bipolar disorder is chronic but manageable

• Medication adherence is essential

• Sleep deprivation may trigger mania

• Early warning signs should prompt medical review

• Avoid alcohol and recreational drugs