AKT · Psychiatry/Mood

Bipolar affective disorder

Overview

Recurrent episodes of mania/hypomania and depression. Mania = ≥1 week elevated/irritable mood + ≥3 symptoms (grandiosity, ↓sleep need, pressured speech, flight of ideas, distractibility, risk-taking) with marked impairment ± psychosis. Hypomania = ≥4 days, no marked impairment/psychosis.

Recognise

Mania: elated/irritable, grandiose, reduced sleep need, pressure of speech, flight of ideas, disinhibition/overspending, psychosis possible
Hypomania: same but milder, ≥4 days, function preserved
Depressive episodes (often dominate the long-term course)

Red flags

Mania with risk to self/others, severe depression, or psychosis → urgent mental health assessment / admission

Differentials & how to tell them apart

Unipolar depressionthe discriminator is any past manic/hypomanic episode

Schizoaffective disorderpsychosis persists ≥2 weeks WITHOUT prominent mood symptoms

ADHDchronic and pervasive, not episodic; no elevated mood/grandiosity

Drug-induced maniastimulants, steroids — temporal link

Investigations

Clinical (collateral history is key). Exclude organic/substance causes. Bloods incl. TFTs; pre-lithium: U&E/eGFR, TFTs, calcium, weight, ECG; pregnancy test before valproate.

Management

1Refer all suspected bipolar to specialist mental health services to confirm diagnosis and treat the acute episode. Do not start antipsychotics except on consultant advice.
1Acute mania: oral antipsychotic (haloperidol, olanzapine, quetiapine or risperidone). Taper/stop any antidepressant.Gate: If first antipsychotic ineffective/not tolerated → try a second; only then add lithium (or valproate)
2Bipolar depression: quetiapine, OR olanzapine ± fluoxetine, OR lamotrigine. Avoid antidepressant monotherapy.
3Long-term: lithium first-line prophylaxis; add valproate if lithium alone ineffective (not in women of childbearing potential).

Lithium — first-line long-term prophylaxis; narrow therapeutic index — see Monitor

Sodium valproate — AVOID in women of childbearing potential (teratogen); under-55s only if 2 specialists agree

Quetiapine / olanzapine — acute mania and bipolar depression

Lamotrigine — bipolar depression; risk of SJS — titrate slowly

Key points

Valproate: pregnancy-prevention programme mandatory in females of childbearing potential; MHRA — males/under-55s only if two specialists document no alternative. Pregnancy: avoid valproate/lithium where possible (lithium → Ebstein anomaly).

Monitor & prognosis

Lithium: levels 12h post-dose, weekly until stable then 3-monthly; U&E + TFTs + calcium 6-monthly (nephrotoxic, hypothyroid, hypercalcaemia). Antipsychotic metabolic monitoring ≥12 months.

Lifelong relapsing-remitting; high suicide risk.

Source: NICE CKS Bipolar disorder (2025) / NG185