Bipolar Disorder
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Direct answer
Bipolar I disorder requires at least one manic episode — elevated or irritable mood with increased activity or energy lasting at least one week, or any duration requiring hospitalisation. Bipolar II disorder requires at least one hypomanic episode of four days or more plus a major depressive episode, with no manic episode ever. Lithium remains the gold-standard mood stabiliser for maintenance, supported by valproate, lamotrigine and atypical antipsychotics according to phase and pattern of illness.
What you must remember
- Mania rule: elevated, expansive or irritable mood plus increased energy or activity, with three or more additional symptoms (four if mood is only irritable) — grandiosity, decreased need for sleep, pressured speech, flight of ideas, distractibility, increased goal-directed activity and risky behaviour — for one week or hospitalisation.
- Hypomania: similar but lasting at least four days, without marked impairment, psychosis or hospitalisation.
- Rapid cycling: four or more episodes within twelve months; antidepressants should be avoided as they may worsen cycling.
- Lithium: therapeutic range 0.6–1.2 mEq/L (maintenance usually 0.6–0.8), trough level twelve hours post-dose; adverse effects include tremor, polyuria from nephrogenic diabetes insipidus, hypothyroidism and weight gain; it is teratogenic (Ebstein anomaly risk) and uniquely has evidence for reducing suicide risk.
- Lithium baseline and monitoring: thyroid function, renal function with electrolytes, calcium, ECG and pregnancy testing before starting, with periodic re-testing.
- Valproate: effective for acute mania and maintenance, but substantially raises malformation risk including neural tube defects, so it should be avoided in women who may become pregnant unless there is no alternative with reliable contraception; monitor liver function and blood counts; watch for weight gain, tremor, hair loss and thrombocytopenia.
- Phase-specific choices: acute mania — lithium, valproate or an atypical antipsychotic (olanzapine, risperidone, quetiapine, aripiprazole), combined in severe cases; bipolar depression — quetiapine, lurasidone or lamotrigine; lamotrigine must be titrated slowly for Stevens-Johnson syndrome risk.
Common confusion
Bipolar depression misdiagnosed as unipolar depression is the clinical trap — the missed hypomania history leads to antidepressant monotherapy and a manic switch, so screening for past elevation is standard before treating any depression. Mania with psychotic features can mimic schizophrenia, but prominent mood symptoms, an episodic course and a family history of mood disorder favour bipolar disorder. Rapid, ultradian mood shifts triggered by interpersonal events point towards borderline personality disorder, whereas bipolar episodes are sustained for days to weeks and arise independently of context.
Exam-focused takeaway
NEET-PG anchors this topic on the duration boundary separating mania from hypomania, the definition of bipolar II, and lithium — its therapeutic range, twelve-hour trough timing, monitoring panel, adverse effects and teratogenicity are perennial one-liners. Expect stems on valproate avoidance in young women, carbamazepine interactions (enzyme induction with oral contraceptive failure, and hyponatraemia), lamotrigine's slow titration, and phase-specific management, especially avoiding antidepressant monotherapy. A vignette of decreased need for sleep with buying sprees and grandiosity is the classic mania stem whose answer is an atypical antipsychotic or lithium.
Frequently asked questions
What separates mania from hypomania?
Duration and severity — mania lasts at least one week (or needs hospitalisation) with marked impairment or psychosis; hypomania lasts at least four days without marked impairment.
What is the therapeutic range of lithium?
0.6–1.2 mEq/L, with about 0.6–0.8 for maintenance; levels are drawn twelve hours after the last dose.
What monitoring does lithium require?
Baseline thyroid function, renal function with electrolytes, calcium, ECG and pregnancy testing, with periodic repeat testing during treatment.
Which mood stabiliser is avoided in women of childbearing age?
Valproate, because of neural tube and other malformation risk — it is used only when no alternative exists, with effective contraception.
What is rapid cycling?
Four or more mood episodes within twelve months; antidepressants are best avoided in this pattern.
Which drugs suit bipolar depression?
Quetiapine, lurasidone and lamotrigine; antidepressant monotherapy is avoided in bipolar disorder.