Epidemiology

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Etiology

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Subtypes and variants

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Cyclothymia (Cyclothymic disorder)

Basically a milder form of bipolar disorder

• Symptoms are not severe enough to diagnose bipolar disorder, with
  • Hypomania: not enough for mania
  • Dysthymia: not enough for depression
• But symptoms are more persistent than regular bipolar
• Symptoms last at least 2 years, are present at least half of the time, and are never absent for more than 2 months at a time.

Clinical features

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Mnemonic

• DIGFAST for features of mania: Distractibility, Irresponsibility, Grandiosity, Flight of ideas, Activity increase, Sleep deficit, and Talkativeness.
• SAGECAPS for features of depression: Sleep (insomnia or hypersomnia), Interest loss (Anhedonia), Guilt (low self-esteem), Energy (low energy or fatigue), Concentration (poor concentration or difficulty making decisions), Appetite (decreased appetite or overeating), Psychomotor agitation or retardation, and Suicidal ideation.
  • Imagined a very sad wizard in a fancy hat.

Diagnostics

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Manic episode	Hypomanic episode
• Symptoms more severe	• Symptoms less severe
• 1 week unless hospitalized	• ≥4 consecutive days
• Marked impairment in social or occupational functioning or hospitalization necessary	• Unequivocal, observable change in functioning from baseline • Symptoms not severe enough to cause marked impairment or necessitate hospitalization
• May have psychotic features; makes episode manic by definition	• No psychotic features

• Bipolar I
  • Manic episode(s)
  • Depressive episodes common but not required for diagnosis
• Bipolar II
  • Hypomanic episode(s)
  • ≥1 major depressive episodes

Treatment

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Long-term maintenance treatment

• Pharmacotherapy: Consider continuing the drug(s) that resolved the acute manic or depressive episode.
• Commonly used agents
  • Lithium (preferred): Individualize the dose according to clinical response and serum levels.
    • Adverse effects
      • Diabetes insipidus
      • Hypothyroidism
      • Tremor
      • Ebstein anomaly (teratogenic)
  • Valproic acid, lamotrigine
• Refractory or severe bipolar episodes
  • Combination therapy with a mood stabilizer (e.g., lithium or valproic acid)
  • PLUS atypical antipsychotics (e.g., quetiapine, olanzapine, aripiprazole)
• Severe depression or predominantly depressive bipolar II disorder: Antidepressants may be started after initiating mood stabilizers.

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