Quick Overview
Bipolar disorder is a severe mental illness characterized by episodic mood disturbances with manic/hypomanic and depressive episodes. NICE CG185 provides evidence-based guidance for acute management and long-term relapse prevention. Critical for UK Medical PG: recognize rapid cycling (≥4 episodes/year), understand mood stabilizer selection hierarchy, and implement structured monitoring protocols.
Core Facts & Concepts
Diagnostic Criteria:
- Mania: Elevated/irritable mood ≥7 days (or any duration if hospitalization required) + ≥3 symptoms (grandiosity, decreased sleep, pressured speech, flight of ideas, distractibility, increased goal-directed activity, risk-taking)
- Hypomania: Similar but ≥4 days duration, less severe, no psychotic features, no hospitalization
- Bipolar I: ≥1 manic episode (with/without depression)
- Bipolar II: ≥1 hypomanic + ≥1 major depressive episode
- Rapid cycling: ≥4 mood episodes within 12 months (poorer prognosis, requires treatment modification)
NICE CG185 Mood Stabilizer Hierarchy:
| Line | Acute Mania | Bipolar Depression | Long-term Maintenance |
|---|---|---|---|
| 1st | Haloperidol, olanzapine, quetiapine, or risperidone | Fluoxetine + olanzapine or quetiapine alone | Lithium (first choice) |
| 2nd | Lithium (if 1st line ineffective) | Lamotrigine or lithium | Valproate or olanzapine |
| 3rd | Valproate (acute only, not women of childbearing potential) | Consider lamotrigine + lithium | Lamotrigine (especially for preventing depression) |
Key Dosing Thresholds:
- 💊 Lithium: Target plasma level 0.6-1.0 mmol/L (maintenance); check at 12h post-dose
- 💊 Valproate: CONTRAINDICATED in women of childbearing potential (teratogenic)
- 💊 Lamotrigine: Titrate slowly (risk Stevens-Johnson syndrome); start 25mg daily, increase over 6 weeks
Problem-Solving Approach
Acute Mania Management (NICE CG185):
- Risk assessment first: Assess harm to self/others, safeguarding needs, capacity
- Stop antidepressants if currently prescribed (can worsen mania)
- First-line options (choose based on patient factors):
- Antipsychotic monotherapy: Haloperidol 1.5-3mg/day, olanzapine 15mg/day, quetiapine 300-800mg/day, or risperidone 2-6mg/day
- If already on lithium with subtherapeutic levels: optimize dose first
- Consider combination if partial response at 7-14 days: antipsychotic + lithium or valproate
- Benzodiazepines (e.g., lorazepam 1-2mg) for short-term behavioral control/insomnia
Bipolar Depression Management:
- Review current medication: Optimize mood stabilizer dose if subtherapeutic
- Psychological intervention: CBT or interpersonal therapy (mild-moderate depression)
- First-line pharmacological: Fluoxetine 20-60mg + olanzapine 5-20mg OR quetiapine 300mg/day
- Avoid antidepressant monotherapy (risk of manic switch ~15-20%)
- If treatment-resistant: Consider lamotrigine augmentation
⚠️ Warning: Antidepressant monotherapy in bipolar depression increases manic switch risk. Always use with mood stabilizer or use quetiapine/olanzapine+fluoxetine.
Red Flags 🚩:
- Rapid cycling pattern → worse prognosis, review thyroid function, consider valproate/lamotrigine
- Non-adherence → commonest cause of relapse (60-70% lifetime non-adherence rate)
- Substance misuse → co-occurs in 40-60%, worsens outcomes
Analysis Framework
Rapid Cycling Identification & Management:
- Definition: ≥4 episodes (manic/hypomanic/depressive) in 12 months
- Prevalence: 10-20% of bipolar patients
- Management differences: Avoid antidepressants, prefer valproate or lamotrigine over lithium
Mood Stabilizer Selection Criteria:
| Factor | Lithium | Valproate | Lamotrigine | Antipsychotics |
|---|---|---|---|---|
| Acute mania | ++ | +++ | - | +++ |
| Bipolar depression | + | - | +++ | ++ (quetiapine/olanzapine) |
| Maintenance | +++ (best evidence) | ++ | ++ (prevents depression) | ++ |
| Rapid cycling | + | ++ | ++ | + |
| Pregnancy safety | Contraindicated 1st trimester | Absolutely contraindicated | Relatively safer | Variable |
| Monitoring burden | High (levels, renal, thyroid) | Moderate | Low | Moderate (metabolic) |
Discriminating Features - Mania vs Agitated Depression:
- Mania: Elevated/expansive mood, grandiosity, decreased need for sleep (not just insomnia)
- Agitated depression: Low mood predominates, psychomotor agitation without euphoria, guilt/worthlessness
Visual Aid
Long-term Monitoring Requirements:
| Medication | Baseline | Ongoing Monitoring |
|---|---|---|
| Lithium | U&Es, TFTs, BMI, ECG if cardiac risk | Lithium level weekly until stable then q3mo; U&Es/TFTs q6mo; weight q1yr |
| Valproate | LFTs, FBC, pregnancy test | LFTs/FBC at 6mo then annually; teratogenicity counseling mandatory |
| Lamotrigine | None specific | Rash monitoring (especially weeks 2-8); no routine bloods |
| Antipsychotics | Weight, BMI, lipids, glucose, prolactin | Weight/BMI q3mo for 1yr then annually; lipids/glucose annually |
Key Points Summary
✓ Bipolar I vs II: Mania (≥7 days, severe) vs hypomania (≥4 days, milder); both can have depression
✓ Acute mania first-line (NICE CG185): Antipsychotic monotherapy (haloperidol/olanzapine/quetiapine/risperidone) OR optimize lithium if already prescribed
✓ Bipolar depression first-line: Fluoxetine + olanzapine OR quetiapine monotherapy; never antidepressant alone (manic switch risk)
✓ Maintenance gold standard: Lithium 0.6-1.0 mmol/L (check 12h post-dose, q3mo when stable); monitor U&Es/TFTs q6mo
✓ Rapid cycling (≥4 episodes/year): Consider valproate or lamotrigine over lithium; avoid antidepressants
✓ Valproate: Absolutely contraindicated in women of childbearing potential (teratogenic); use only if pregnancy prevention program in place
✓ Relapse prevention: Structured monitoring, medication adherence support (60-70% lifetime non-adherence), psychological interventions (CBT), early warning signs education
📌 Remember: LITHIUM monitoring - Levels (q3mo), Thyroid (q6mo), U&Es (q6mo), Weight (annually)
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