Psych · General adult psychiatry — bipolar and related disorders
Bipolar I disorder
Also known as Bipolar I · BP-I · Manic-depressive illness · Manic episode · Bipolar mania · Bipolar type I
Exam-exhaustive fellowship leaf on bipolar I disorder — DSM-5-TR and ICD-11 mania gates; epidemiology and suicide risk; acute mania algorithms with lithium, valproate and SGAs; bipolar I depression and STEP-BD antidepressant lesson; BALANCE maintenance; lithium monitoring and anti-suicide evidence; pregnancy and valproate hierarchy; RANZCP/NICE/BAP/CANMAT/APA deltas. FRANZCP-primary, globally tagged.
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Target exams
Red flags
- Mania or mixed features with active suicidal intent, psychosis, or catastrophic risk behaviour — same-day senior review and likely admission
- Antidepressant monotherapy in known or highly suspected bipolar I — switch and destabilisation risk; exam fail
- Lithium toxicity: coarse tremor, ataxia, confusion, vomiting, dysarthria — stop lithium, urgent level, hydrate, escalate
- Valproate in people who can become pregnant without documented pregnancy-prevention counselling — major teratogen hierarchy
- First mania after age ~40, focal neurology, seizure, fever, or fluctuating attention — intensify organic work-up
- Postpartum first fortnight in bipolar I — peak relapse window; protect sleep and re-establish prophylaxis
Meet the patient
A 22-year-old law student is brought in by campus security. Eight days without meaningful sleep. He has drafted a 90-page constitutional theory that will, he explains, abolish prisons — the Prime Minister's office has been emailed. He is singing in the assessment room and says God has been texting him encouragement. His mother, quietly: "He was depressed all winter. This is not him."[17]
Two rules are hiding in that vignette, and examiners test both: psychosis during an elevated pole means mania, not hypomania — and one mania makes the diagnosis of bipolar I forever.[17]
References18ShowHide
- [1]Geddes JR, Goodwin GM, Rendell J, et al. Lithium plus valproate combination therapy versus monotherapy for relapse prevention in bipolar I disorder (BALANCE): a randomised open-label trial Lancet, 2010.PMID 20092882
- [2]Sachs GS, Nierenberg AA, Calabrese JR, et al. Effectiveness of adjunctive antidepressant treatment for bipolar depression N Engl J Med, 2007.PMID 17392295
- [3]Cipriani A, Hawton K, Stockton S, et al. Lithium in the prevention of suicide in mood disorders: updated systematic review and meta-analysis BMJ, 2013.PMID 23814104
- [4]Cipriani A, Barbui C, Salanti G, et al. Comparative efficacy and acceptability of antimanic drugs in acute mania: a multiple-treatments meta-analysis Lancet, 2011.PMID 21851976
- [5]Miura T, Noma H, Furukawa TA, et al. Comparative efficacy and tolerability of pharmacological treatments in the maintenance treatment of bipolar disorder: a systematic review and network meta-analysis Lancet Psychiatry, 2014.PMID 26360999
- [6]Calabrese JR, Keck PE Jr, Macfadden W, et al. A randomized, double-blind, placebo-controlled trial of quetiapine in the treatment of bipolar I or II depression Am J Psychiatry, 2005.PMID 15994719
- [7]Tohen M, Vieta E, Calabrese J, et al. Efficacy of olanzapine and olanzapine-fluoxetine combination in the treatment of bipolar I depression Arch Gen Psychiatry, 2003.PMID 14609883
- [8]Loebel A, Cucchiaro J, Silva R, et al. Lurasidone monotherapy in the treatment of bipolar I depression: a randomized, double-blind, placebo-controlled study Am J Psychiatry, 2014.PMID 24170180
- [9]Goodwin GM, Bowden CL, Calabrese JR, et al. A pooled analysis of 2 placebo-controlled 18-month trials of lamotrigine and lithium maintenance in bipolar I disorder J Clin Psychiatry, 2004.PMID 15096085
- [10]Yatham LN, Kennedy SH, Parikh SV, et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) 2018 guidelines for the management of patients with bipolar disorder Bipolar Disord, 2018.PMID 29536616
- [11]Malhi GS, Bell E, Bassett D, et al. The 2020 Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders Aust N Z J Psychiatry, 2021.PMID 33353391
- [12]Goodwin GM, Haddad PM, Ferrier IN, et al. Evidence-based guidelines for treating bipolar disorder: Revised third edition recommendations from the British Association for Psychopharmacology J Psychopharmacol, 2016.PMID 26979387
- [13]Patorno E, Huybrechts KF, Hernandez-Diaz S Lithium Use in Pregnancy and the Risk of Cardiac Malformations N Engl J Med, 2017.PMID 28854098
- [14]McKnight RF, Adida M, Budge K, et al. Lithium toxicity profile: a systematic review and meta-analysis Lancet, 2012.PMID 22265699
- [15]Merikangas KR, Jin R, He JP, et al. Prevalence and correlates of bipolar spectrum disorder in the world mental health survey initiative Arch Gen Psychiatry, 2011.PMID 21383262
- [16]Bowden CL, Brugger AM, Swann AC, et al. Efficacy of divalproex vs lithium and placebo in the treatment of mania. The Depakote Mania Study Group JAMA, 1994.PMID 8120960
- [17]Grande I, Berk M, Birmaher B, et al. Bipolar disorder Lancet, 2016.PMID 26388529
- [18]Thase ME, Macfadden W, Weisler RH, et al. Efficacy of quetiapine monotherapy in bipolar I and II depression: a double-blind, placebo-controlled study (the BOLDER II study) J Clin Psychopharmacol, 2006.PMID 17110817