Management of Bipolar Disorder

Author: Kim S. Griswold, Linda F. Pessar
Date: Sept 15, 2000

Bipolar disorder most commonly is diagnosed in persons between 18 and 24 years of age. The clinical presentations of this disorder are broad and include mania, hypomania and psychosis. Frequently associated comorbid conditions include substance abuse and anxiety disorders. Patients with acute mania must be evaluated urgently. Effective mood stabilizers include lithium, valproic acid and carbamazepine. A comprehensive management program, including collaboration between the patient's family physician and psychiatrist, should be implemented to optimize medical care. (Am Fam Physician 2000;62:1343-53, 1357-8.)

Bipolar disorder is characterized by variations in mood, from elation and/or irritability to depression. This disorder can cause major disruptions in family, social and occupational life. Bipolar I disorder is defined as episodes of full mania alternating with episodes of major depression. Patients with mania often exhibit disregard for danger and engage in high-risk behaviors such as promiscuous sexual activity, increased spending, violence, substance abuse and driving while intoxicated.

Bipolar II disorder is characterized by recurrent episodes of major depression and hypomania. Hypomania is manifested by an elevated and expansive mood. The behaviors characteristic of hypomania are similar to those of mania but without gross lapses of impulse and judgment. Hypomania does not cause impairment of function and may actually enhance function in the short term.

Bipolar I disorder is typically diagnosed when patients are in their early 20s. Manic symptoms can rapidly escalate over a period of days and frequently follow psychosocial stressors. Some patients initially seek treatment for depression. Other patients may appear irritable, disorganized or psychotic. Differentiating true mania from mania resulting from secondary causes can be challenging (Table 1).(1,2)

Bipolar II disorder typically is brought to medical attention when the patient is depressed. A careful history will usually illuminate the diagnosis. Some depressed patients exhibit hypomania when given antidepressants.(3) This variation is sometimes referred to as bipolar III disorder. The criteria for major depressive episode and manic episode, as described in the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV), are summarized in Table 2.(4)


The lifetime prevalence of bipolar disorder is 1 percent, which compares to a lifetime prevalence of 6 percent for unipolar depression.(5) The prevalence of bipolar disorder does not differ in males and females.(6) The disorder affects persons of all ages. The epidemiologic catchment area study revealed the highest prevalence in the 18-to-24-year age group.(7) In some patients, however, bipolar disorder does not become manifest until patients are older. One study reported new-onset bipolar disorder in patients older than 60 years.(8)

The incidence of bipolar disorder is increased in first-degree relatives of persons with the disorder, as is the incidence of other mood disorders.(9) One study revealed a 13 percent risk of bipolar disorder among offspring of persons with the disorder.(10) The risk of unipolar depression was 15 percent, and the risk of schizoaffective disorder was 1 percent.(10) The mode of inheritance remains unclear, and no algorithm exists to predict the risk of bipolar disorder.(11) Because of the familial association, genetic counseling should be offered to patients and their families as part of comprehensive educational and supportive approaches.

Clinical Presentations

Patients with symptoms of a mood disorder often do not meet the full criteria for bipolar disorder. Many patients with bipolar disorder are diagnosed as having depression. If agitation is prominent, hypomanic symptoms may be misunderstood as representing an anxiety state. Accurate diagnosis of bipolar disorder requires obtaining a comprehensive psychiatric history.


Hyperactivity is the most common behavioral manifestation of mania in children.12 Manic children may exhibit irritability or temper tantrums.(13) The differential psychiatric diagnoses include attention-deficit/ hyperactivity disorder, conduct disorder and schizophrenia.(14)


Manic symptoms in adolescents are similar to those in adults. Florid psychosis can be a presentation of bipolar disorder in adolescents. Included in the differential diagnosis of mania in adolescents are substance abuse and schizophrenia, which may be challenging to distinguish from bipolar disorder. The normal risk-taking behavior in some adolescents must be distinguished from the reckless nature of manic symptoms.


The course of bipolar disorder during pregnancy is variable. Management requires sustained collaboration between the patient's family physician and her psychiatrist. A patient with bipolar disorder should be encouraged to plan pregnancy so that the dosage of her psychiatric medication can be slowly tapered. The risk of relapse is increased with abrupt discontinuation.(15)

Relapse during pregnancy must be treated aggressively with mood stabilizers. The patient should be admitted to the hospital. If lithium therapy is required, the patient should be counseled regarding the increased risk of cardiovascular malformations in fetuses exposed to lithium. Breast-feeding during lithium therapy is discouraged because lithium is excreted in breast milk.(16)

During the postpartum period, worsening of affective symptoms may occur, including rapid cycling, which is sometimes refractory to drug therapy.(17) Women who have worsening of symptoms postpartum may have an increased risk of recurrence.

Comorbid Conditions

Studies of primary care patients with major depressive disorders have demonstrated a tendency toward certain comorbid conditions. In one study,(18) more than 42 percent of patients meeting the criteria for a major depressive disorder (including bipolar disorder) had lifetime histories of substance abuse. In another study,(19) the frequency of substance abuse was 39 percent in adolescents who had symptoms of bipolar disorder. Another study(20) revealed a high prevalence of moderate to severe anxiety disorders in association with bipolar disorder, as well as a high prevalence of psychosocial morbidity.

While many patients with bipolar disorder show gradual improvement in the first several years after diagnosis, a substantial subgroup experiences poor adjustment in one or more areas of functioning.(21) In a study of psychiatric patients who were evaluated 30 to 40 years after the index hospitalization for mania, 24 percent of the sample was considered to be occupationally incapacitated.(22)



If a patient with symptoms of acute mania presents to the office, a psychiatrist should be consulted, and the patient should be evaluated urgently. The family physician must know the legal requirements in the community for transferring a patient with acute mania from the office to the hospital. Often, police must be involved. It is inappropriate to expect family members to transport the patient from the office to the hospital, because family members may not appreciate the irrationality of manic thinking and the unpredictability of manic behavior.

The family physician and psychiatrist have the responsibility to inform, educate and support family members in terms of the possible need for the family to petition the court for the patient's admission to a psychiatric unit. It is important to recognize, and to try to allay, the guilt and regret family members often feel in these circumstances.

Patients with newly diagnosed bipolar disorder require a medical evaluation along with a psychiatric evaluation. Table 323 lists the recommended laboratory tests for patients evaluated on an inpatient or an outpatient basis. Computed tomography or magnetic resonance imaging and electroencephalography are second-line options in the evaluation of treatment-resistant patients. These studies are not routinely required without a specific clinical reason. Similarly, the need for electrocardiography in patients younger than 40 years rests with the clinician's judgment.

If necessary, and if the patient has been in good general health, mood stabilizers, as well as other drugs used in the treatment of bipolar disorder, can be started before the test results are available. If the need to begin treatment is urgent, medication can be given even before laboratory specimens are obtained.


(14.) Weller EB, Weller RA, Fristad MA. Bipolar disorder in children: misdiagnosis, underdiagnosis, and future directions. J Am Acad Child Adolesc Psychiatry 1995;34:709-14.

(15.) Altshuler LL, Cohen L, Szuba MP, Burt VK, Gitlin M, Mintz J. Pharmacologic management of psychiatric illness during pregnancy: dilemmas and guidelines. Am J Psychiatry 1996;153:592-606.

(16.) Packer S. Family planning for women with bipolar disorder. Hosp Community Psychiatry 1992;43: 479-82.

(17.) Altshuler LL, Hendrick V, Cohen LS. Course of mood and anxiety disorders during pregnancy and the postpartum period. J Clin Psychiatry 1998; 59(suppl 2):29-33.

(18.) Coyne JC, Fechner-Bates S, Schwenk TL. Prevalence, nature, and comorbidity of depressive disorders in primary care. Gen Hosp Psychiatry 1994; 16:267-76.

(19.) West SA, Strakowski SM, Sax KW, McElroy SL, Keck PE, McConville BJ. Phenomenology and comorbidity of adolescents hospitalized for the treatment of acute mania. Biol Psychiatry 1996;39: 458-60.

(20.) Nease DE, Volk RJ, Cass AR. Investigation of a severity-based classification of mood and anxiety symptoms in primary care patients. J Am Board Fam Pract 1999;12:21-31.

(21.) Goldberg JF, Harrow M, Grossman LS. Course and outcome in bipolar affective disorder: a longitudinal follow-up study. Am J Psychiatry 1995;152: 379-84.

(22.) Coryell W, Scheftner W, Keller M, Endicott J, Maser J, Klerman GL. The enduring psychosocial consequences of mania and depression. Am J Psychiatry 1993;150:720-7.

(23.) Steering Committee. Treatment of bipolar disorder. The Expert Consensus Guideline Series. J Clin Psychiatry 1996;57(suppl 12A):3-88.

(24.) Nutting PA, Franks P, Clancy CM. Referral and consultation in primary care: do we understand what we're doing? [Editorial] J Fam Pract 1992;35:21-3.

(25.) Kates N, Craven MA, Crustolo AM, Nikolaou L, Allen C, Farrar S. Sharing care: the psychiatrist in the family physician's office. Can J Psychiatry 1997; 42:960-5.

(26.) Hartmann PM. Strategies for managing depression complicated by bipolar disorder, suicidal ideation, or psychotic features. J Am Board Fam Pract 1996;9:261-9.

(27.) DeVane CL, Nemeroff CB. 1998 Guide to psychotropic drug interactions. Primary Psychiatry 1998;5:36-75.

(28.) Strakowski SM, McElroy SL, Keck PE, West SA. Suicidality among patients with mixed and manic bipolar disorder. Am J Psychiatry 1996;153:674-6.

(29.) Simpson SG, Jamison KR. The risk of suicide in patients with bipolar disorders. J Clin Psychiatry 1999;60(suppl 2):53-6.

The Authors

KIM S. GRISWOLD, M.D., M.P.H., is assistant professor of family medicine and psychiatry in the Department of Family Medicine at the State University of New York (SUNY) at Buffalo School of Medicine and Biomedical Sciences. She received a master's degree in public health from Yale University, New Haven, Conn., and completed a faculty development fellowship in primary care at Michigan State University College of Human Medicine, East Lansing. After graduating from the SUNY-Buffalo School of Medicine and Biomedical Sciences, she completed a family practice residency at Buffalo (N.Y.) General Hospital.

LINDA F. PESSAR, M.D., is a psychiatrist and associate professor of clinical psychiatry and family medicine at SUNY-Buffalo School of Medicine and Biomedical Sciences, where she is also director of medical student education in psychiatry. She received a medical degree from Columbia University College of Physicians and Surgeons, New York City, and completed a psychiatry residency at New York State Psychiatric Institute/Columbia Presbyterian Medical Center, New York City.

Address correspondence to Kim S. Griswold, M.D., M.P.H., Department of Family Medicine, State University of New York at Buffalo, Center for Urban Research in Primary Care, 135 Grant St., Buffalo, NY 14213. Reprints are not available from the authors.

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