General Overview

  • Mania
    • Distinct period of abnormally persistently elevated, expansive or irritable mood and goal-directed activity/energy >1w (or hospitalization) most of the day nearly every day
    • ≥3 (or 4 if mood only irritable)
      • Grandiosity (inflated self esteem)
      • Sleep (decreased need, eg. rested after 3h of sleep)
      • Talkative
      • Pleasurable activities that have high potential for Painful consequences
      • Activity (goal-directed) or psychomotor Agitation
      • Ideas (flight of)
      • Distractibility
    • Impaired function, not attributable to substance or medical condition
  • Hypomania
    • Meets criteria but lasts only 4-6 days
    • No marked impairment in function
    • Absent psychotic features (if present, would be manic)
  • Bipolar I
    • ≥ one manic or mixed episode
  • Bipolar II
    • ≥1 MDE + ≥1 hypomanic episode (>4d, not severe enough to affect function, not need hospitalization, no psychotic features)
  • Specifiers: with anxious distress, depressed with mixed features, hypo/manic with mixed features, melancholic features, atypical features, mood-congruent or -incongruent psychotic features, catatonia, peripartum onset, seasonal pattern, rapid cycling (4+ mood episodes in a 1 yr)
  • Cyclothymia
    • Numerous hypomanic and depressive symptoms not meeting criteria ≥2 years (never asymptomatic >2mo)
    • Impaired function


  • Anxiety
  • Depression
  • Personality (Narcissitic, Borderline, Antisocial)
  • Substance use disorders
  • Medications
  • Medical condition (endocrine)


  • CBC, electrolytes (Glucose, Cr), lipids, LFT and Bili, INR, TSH, EKG
  • bhCG, prolactin
  • Urine analysis
  • Urine toxicology
  • Monitoring
    • Lithium:
      • Levels weekly until stable then q3-6 months (target 0.6-0.8mmol/L)
      • LFT, electrolytes (Urea, Cr, Calcium), TSH q3-6mo
    • Divalproex: Levels do not need to be monitored
      • LFT, CBC q6mo then yearly

Acute Management

Acute Mania

  • Assess safety
  • If on long-term treatment optimize dose levels, and then consider adjunct antipsychotic
  • Monotherapy:
    • Mood stabilizers - Lithium, Divalproex
      • Lithium more effective in euphoric mania
      • Divalproex in Mixed episodes or rapid cycling
    • Antipsychotics - Risperidone, quetiapine, olanzapine, aripripazole, asenapine, ziprasidone, paliperidone ER
      • Psychosis/agitation
  • Adjunctive therapy with lithium or divalproex (20% higher response rate than mood stabilizer alone)
    • Risperidone, quetiapine, olanzapine, aripripazole, asenapine

Acute Bipolar I Depression

  • Monotherapy
    • Lithium, lamotrigine, quetiapine, quetiapine XR
  • Combination therapy
    • Lithium or Divalproex AND SSRI or Buproprion
    • Olanzapine AND SSRI (fluoxetine)

Acute Bipolar II Depression

  • First line: Quetiapine
  • Second line: Lithium, lamotrigine, divalproex or combination as above


  • Ensure adherence
  • First line for mania and depression: Lithium, divalproex, quetiapine
    • Lithium side effects:
      • Neuro (ataxia, confusion, agitation, tremor, seizure)
      • Cardiac (bradycardia, prolonged QT)
      • Renal (nephrogenic diabetes insipidus)
      • Thyroid (hypo and hyperthyroidism)
    • Consider for the prevention of mania: Risperidone, aripiprazole, olanzapine
    • Consider for the prevention of depression: Lamotrogine

Psychosocial interventions

  • Group psychoeducation, CBT, IPSRT (interpersonal social rhythm therapy) useful adjuncts in acute depressive episodes and maintenance
    • Brief psychoeducation
    • Family-focused treatment approach (caregivers improve illness management skills and self-care)
    • Internet based strategies