Bipolar I Disorder

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Basics

Description

  • Bipolar I (BP-I) is an episodic mood disorder of at least one manic or mixed (mania and depression) episode that causes marked impairment, psychosis, and/or hospitalization; major depressive episodes are not required but usually occur.
  • Symptoms are not caused by a substance or general medical condition.

Geriatric Considerations
In new onset in older patients (>50 years of age) a workup for organic or chemically induced pathology is strongly recommended. Medications for adults are generally found efficacious in older adults, although high quality studies are lacking. Pay strict attention to pharmacokinetic issues, drug–drug interactions, side effects, and need for ongoing monitoring (e.g., lithium level and renal monitoring q3–6mo with lithium use).

Pediatric Considerations
Diagnosis is based on the same set of symptoms applied to adults. Need for clarity of symptoms is critical to differentiate between attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), disruptive mood dysregulation, and other diagnoses with overlapping symptoms that are common in childhood.

Pregnancy Considerations

  • Pregnancy does not reduce risk of mood episodes.
  • Need to weigh risk of exposure to mood episode to that of medication
  • Avoid divalproex due to high teratogenicity risk.
  • Postpartum carries high risk of severe acute episode with psychosis and/or infanticidal ideation.

Epidemiology

Onset usually between 15 and 30 years of age, average of 25 years

Prevalence
  • 1.0–1.6% lifetime prevalence
  • Equal among men and women (manic episodes more common in men; depressive episodes more common in women)
  • Equal among races; however, clinicians tend to diagnose schizoaffective in African Americans with BP-I.

Etiology and Pathophysiology

Genetic predisposition and major life stressors can trigger initial and subsequent episodes:

  • Dysregulation of biogenic amines or neurotransmitters (particularly serotonin, norepinephrine, and dopamine)
  • Magnetic resonance imaging (MRI) findings suggest abnormalities in prefrontal cortical areas, striatum, and amygdala that predate illness onset (1)[C].
Genetics
  • Monozygotic twin concordance 40–70%
  • Dizygotic twin concordance 5–25%
  • 50% have at least one parent with a mood disorder.
  • First-degree relatives are 7 times more likely to develop BP-I than the general population.

Risk Factors

Genetics, major life stressors, or substance abuse

General Prevention

No known way to prevent onset, but treatment adherence and education help to prevent relapses.

Commonly Associated Conditions

Substance abuse (60%), ADHD, anxiety disorders (~50%), and eating disorders

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Basics

Description

  • Bipolar I (BP-I) is an episodic mood disorder of at least one manic or mixed (mania and depression) episode that causes marked impairment, psychosis, and/or hospitalization; major depressive episodes are not required but usually occur.
  • Symptoms are not caused by a substance or general medical condition.

Geriatric Considerations
In new onset in older patients (>50 years of age) a workup for organic or chemically induced pathology is strongly recommended. Medications for adults are generally found efficacious in older adults, although high quality studies are lacking. Pay strict attention to pharmacokinetic issues, drug–drug interactions, side effects, and need for ongoing monitoring (e.g., lithium level and renal monitoring q3–6mo with lithium use).

Pediatric Considerations
Diagnosis is based on the same set of symptoms applied to adults. Need for clarity of symptoms is critical to differentiate between attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), disruptive mood dysregulation, and other diagnoses with overlapping symptoms that are common in childhood.

Pregnancy Considerations

  • Pregnancy does not reduce risk of mood episodes.
  • Need to weigh risk of exposure to mood episode to that of medication
  • Avoid divalproex due to high teratogenicity risk.
  • Postpartum carries high risk of severe acute episode with psychosis and/or infanticidal ideation.

Epidemiology

Onset usually between 15 and 30 years of age, average of 25 years

Prevalence
  • 1.0–1.6% lifetime prevalence
  • Equal among men and women (manic episodes more common in men; depressive episodes more common in women)
  • Equal among races; however, clinicians tend to diagnose schizoaffective in African Americans with BP-I.

Etiology and Pathophysiology

Genetic predisposition and major life stressors can trigger initial and subsequent episodes:

  • Dysregulation of biogenic amines or neurotransmitters (particularly serotonin, norepinephrine, and dopamine)
  • Magnetic resonance imaging (MRI) findings suggest abnormalities in prefrontal cortical areas, striatum, and amygdala that predate illness onset (1)[C].
Genetics
  • Monozygotic twin concordance 40–70%
  • Dizygotic twin concordance 5–25%
  • 50% have at least one parent with a mood disorder.
  • First-degree relatives are 7 times more likely to develop BP-I than the general population.

Risk Factors

Genetics, major life stressors, or substance abuse

General Prevention

No known way to prevent onset, but treatment adherence and education help to prevent relapses.

Commonly Associated Conditions

Substance abuse (60%), ADHD, anxiety disorders (~50%), and eating disorders

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