Bipolar Disorder

History

• Family history of bipolar disorder

• Previous manic episodes or rapid mood swings

• Functional impairment during mood episodes

• Antidepressant use without concurrent mania prophylaxis

• Possible drug-induced psychosis (illicit substances)

• Comorbid anxiety or substance use disorders

• Mixed features (coexisting manic and depressive symptoms)

Diagnosis

• Elevated, irritable, or expansive mood plus ≥3 DIGFAST symptoms: Distractibility, Indiscretion (risky behaviour), Grandiosity, Flight of ideas, Activity increase, Sleep decrease, Talkativeness.

• Exclude medical causes (e.g. thyroid disorders).

• Use DSM-5 criteria for bipolar spectrum.

• Bipolar I: ≥7 days of mania (or hospitalisation), severe functional impairment or psychosis.

• Bipolar II: Hypomania (≥4 days) plus major depression, no severe functional impairment or psychosis.

Management

• Acute Mania

  • Initial actions:

    • Inform patient of likely mania, assess insight.

    • Consider collateral history with consent.

    • Arrange psychiatric admission if necessary.

    • Crisis assessment if risk to self or others.

  • Medications (oral):

    • Olanzapine 5 mg PO stat or risperidone 0.5 mg nocte.

  • If IM needed:

    • Midazolam 5 mg IM or droperidol/olanzapine 5 mg IM.

  • Monitor vitals and side effects.

• Bipolar Depression

  • First-line: SSRI + mood stabiliser (e.g. lithium) or second-generation antipsychotic.

  • Monotherapy option: Quetiapine.

  • Avoid prolonged antidepressant use: Taper off within 1–2 months to reduce mania risk.

  • Assess suicidality.

• Long-Term Management

  • Educate family to recognise early mania signs.

  • Offer referrals to bipolar support networks.

  • Ongoing CBT, encourage regular aerobic exercise (150 min/week).

  • Psychoeducation to improve adherence and recognise relapse triggers.

  • Monitor prophylaxis medication adherence and metabolic parameters.

  • Screen for STI, ensure contraception if indicated.

  • Discourage illicit drugs, maintain regular sleep patterns.

  • Routine screening for comorbidities (diabetes, dyslipidaemia).

  • Regular follow-ups for mental state review and therapy adjustments.

Subtypes

• Type 1: Manic episodes ≥7 days or requiring hospitalisation, possibly with psychosis or marked functional impairment.

• Type 2: Hypomania (≥4 days + ≥3 DIGFAST symptoms) plus major depression, no significant functional impairment or psychosis.

Notes

• Use haloperidol or metoclopramide cautiously in Parkinson’s disease (EPSE risk).

• Benzodiazepines have high complication risks in certain populations.

• Antidepressants can induce mania; use cautiously and with mood stabilisers.

• Regularly review medications to minimise polypharmacy.

• Low-dose antipsychotics (e.g. olanzapine 2.5 mg PO/IM) can be used off-label for acute delirium.