Bipolar Disorder: Episodes of Depression and Abnormally Elevated Mood

Bipolar disorder causes distinct episodes of depression and abnormally elevated or irritable mood. Mania and hypomania share characteristic changes in energy, sleep, thinking and behaviour, but differ in duration and severity. Accurate diagnosis guides mood stabilising treatment, relapse prevention and urgent protection during high risk episodes.

What bipolar disorder is Bipolar disorder is a long term mood disorder causing episodes of depression and abnormally elevated or irritable mood. These elevated episodes are called mania or hypomania. They involve sustained changes in mood, energy, activity, sleep and behaviour that differ clearly from usual functioning. People may have long periods of stable mood between episodes. Bipolar disorder is not ordinary moodiness or a rapid response to everyday events. Mania and hypomania Mania lasts at least seven days under DSM framing, or any duration when hospitalisation is required. It causes marked impairment, serious risk or psychotic features. Hypomania lasts at least four consecutive days and is observable by others. Hypomania does not cause marked impairment, require hospitalisation or include psychosis. Psychosis makes the episode mania. The elevated mood symptom cluster Episodes involve elevated, expansive or irritable mood together with increased energy or activity. Associated features include decreased sleep need, grandiosity, pressured speech, flight of ideas, distractibility and increased goal directed activity. Psychomotor agitation and risky behaviour can include spending, gambling, reckless driving, substance use or sexual disinhibition. Reduced need for sleep A reduced need for sleep differs from insomnia. The person may sleep only a few hours yet feel rested, energised and ready for further activity. They may work overnight, message people repeatedly or begin several ambitious projects without feeling tired. Reduced sleep can also trigger or intensify an emerging manic or hypomanic episode. Grandiosity, speech and thought changes Grandiosity ranges from unusual overconfidence to fixed beliefs about exceptional power, wealth, spiritual status or influence. Pressured speech is rapid, forceful and difficult to interrupt. Flight of ideas causes thoughts to move quickly between loosely connected topics. Attention may be repeatedly diverted by unimportant sounds, objects or new ideas. Severe thought disorganisation or fixed implausible beliefs can indicate psychosis. Increased activity and risky behaviour Goal directed activity may increase socially, professionally, creatively, sexually or financially. A person may establish businesses, undertake unrealistic projects or contact many people throughout the night. Risky behaviour can include uncontrolled spending, gambling, reckless driving, unsafe sex or substance use. These consequences can persist long after the mood episode has settled. Psychosis in mania Mania can include hallucinations, delusions or severe thought disorganisation. Themes may involve special powers, persecution, religious missions, exceptional wealth or unusual personal importance. Psychosis makes an elevated episode mania, even when symptoms have lasted fewer than seven days. Mania with psychosis requires urgent specialist assessment because insight and safety can deteriorate rapidly. Mixed features Manic and depressive symptoms can occur together during one episode. A person may feel energised and agitated while also hopeless, guilty or suicidal. Modern diagnostic systems may describe this as an episode with mixed features or a mixed episode. Mixed presentations can increase impulsivity and suicide risk and require careful urgent assessment. Bipolar I and Bipolar II Bipolar I disorder requires at least one full manic episode. A depressive episode is common but is not required for the formal diagnosis. Bipolar II disorder requires at least one hypomanic episode and one major depressive episode, without any full manic episode. Bipolar II is not simply mild Bipolar I because depressive burden and suicide risk can be substantial. Bipolar depression Bipolar depressive episodes can look clinically identical to unipolar depression. Symptoms include low mood, loss of pleasure, fatigue, sleep or appetite change, guilt, poor concentration and suicidal thoughts. The current depressive symptoms cannot establish whether the broader illness is bipolar or unipolar. A lifetime history of mood elevation, behaviour change and treatment response is therefore essential. Why previous elevation must be explored NICE advises asking adults presenting with depression about previous overactivity or disinhibited behaviour. A period lasting four days or longer should prompt consideration of specialist mental health assessment. Missing this history can lead to inappropriate antidepressant monotherapy and inadequate relapse prevention. Previous antidepressant related elevation, postpartum episodes or unusually reduced sleep need can provide important clues. Assessment and differential diagnosis Diagnosis requires a detailed lifetime history of episode duration, sleep, behaviour, consequences, family history, substances and treatment response. ADHD is usually a persistent developmental pattern, while bipolar changes occur in distinct episodes. Personality related emotional instability, psychotic disorders, trauma and substance related states can overlap with bipolar symptoms. Hyperthyroidism, corticosteroids, stimulants, neurological illness, intoxication and withdrawal can also produce manic like presentations. Clinical and collateral assessment The clinician assesses mood, activity, speech, thought form, perception, insight, judgement and decision making capacity. Risk assessment includes suicide, self neglect, aggression, driving, spending, sexual behaviour and vulnerability to exploitation. Information from a trusted relative or friend can be valuable because insight may be reduced during mania. Collateral information should support rather than replace listening directly to the person. Investigations No blood test or brain scan confirms bipolar disorder. Tests are selected to exclude physical causes and prepare for treatment. They can include thyroid, kidney, liver, blood count, metabolic, toxicology and pregnancy assessments according to circumstances. Urgent investigation should not delay crisis containment when behaviour creates immediate danger. Risk and urgent referral NICE recommends urgent specialist referral when mania or severe depression is suspected. Immediate danger to the person or others also requires urgent crisis assessment. Hospital care may be necessary for psychosis, dangerous disinhibition, severe self neglect or inability to accept safe community treatment. Emergency services are required when risk is imminent or urgent medical stabilisation is needed. Acute mania treatment Acute care aims to reduce overactivity, restore sleep, treat psychosis and prevent harm. NICE recommends an antipsychotic such as haloperidol, olanzapine, quetiapine or risperidone when appropriate. Choice considers previous response, physical health, adverse effects and personal preference. Lithium or valproate may be added in selected specialist pathways when antipsychotic treatment is insufficient. Antidepressants during mania When mania or hypomania develops during antidepressant monotherapy, NICE advises considering stopping the antidepressant. An antipsychotic is offered whether or not the antidepressant is stopped. If an antidepressant is already combined with a mood stabiliser, stopping the antidepressant may still be considered. Medication changes require supervision because both withdrawal and continuing mood elevation require management. Antidepressants and bipolar depression Antidepressant monotherapy is generally avoided because it can provoke mania, hypomania, mixed symptoms or faster cycling. When an antidepressant is used, it forms part of a bipolar treatment plan with mood stabilising cover. New reduced sleep need, agitation or increased activity requires prompt review rather than simply increasing the antidepressant. The decision considers previous switching, episode pattern and current suicide risk. Treating bipolar depression NICE recommends bipolar specific psychological therapy or appropriately adapted cognitive behavioural, interpersonal or couples therapy. Medication options include quetiapine or fluoxetine combined with olanzapine. Olanzapine alone or lamotrigine can be considered according to preference, previous response and specialist advice. Treatment is monitored for emerging mania, hypomania, mixed symptoms or worsening depression. Long term treatment Long term care aims to prevent manic and depressive relapse while preserving functioning and physical health. NICE describes lithium as the most effective long term pharmacological treatment and recommends it first line. An effective acute medicine may sometimes continue, depending on previous response and relapse pattern. Stopping long term treatment requires gradual reduction and close monitoring for early relapse. Lithium principles Lithium is a mood stabilising medicine used for relapse prevention and selected acute treatment. It has a narrow therapeutic index, meaning effective and toxic concentrations are relatively close. Plasma concentrations guide dosing, and stable treatment can become unsafe after dehydration or medicine interactions. Lithium is started through specialist or formal shared care arrangements. Starting and monitoring lithium Before lithium, NICE recommends weight or BMI, full blood count, kidney function, calcium and thyroid testing. An ECG is arranged when cardiovascular disease or relevant risk factors are present. Plasma levels are measured after starting, after dose changes and regularly during treatment. NICE recommends levels every three months during the first year. Continuing lithium monitoring After the first year, plasma levels are usually checked every six months. Three monthly monitoring continues for older people and others with interactions, higher levels, poor control or organ related risks. Kidney function, thyroid function, calcium and weight or BMI are checked at least every six months. More frequent monitoring is required when renal function declines or symptoms suggest thyroid dysfunction. Lithium toxicity Possible toxicity causes worsening diarrhoea, vomiting, weakness, drowsiness, coarse tremor and poor coordination. Ataxia, slurred speech, confusion, blurred vision or marked neurological change are serious warning signs. The person should stop further doses and obtain urgent medical assessment when toxicity is suspected. A plasma level is measured urgently, but symptoms and kidney function also guide treatment. Lithium interactions and dehydration Vomiting, diarrhoea, fever and heavy sweating can cause dehydration and raise lithium concentrations. NSAIDs, ACE inhibitors, angiotensin receptor blockers and some diuretics can also increase toxicity risk. People taking lithium should check before using new prescriptions, supplements or over the counter medicines. Lithium should not be restarted independently after an illness related interruption. Lithium and pregnancy Lithium exposure during early pregnancy is associated with an increased risk of fetal heart malformations. The absolute fetal risk must be weighed against severe maternal relapse risk through specialist perinatal care. Lithium levels change during pregnancy, childbirth and the postnatal period and require closer monitoring. Anyone planning pregnancy or discovering pregnancy should seek urgent advice and should not stop lithium abruptly. Valproate safety Valproate can reduce manic symptoms but has serious reproductive harms and is highly restricted in the United Kingdom. For most people, effective alternatives should be considered first. Valproate must not be started in primary care for bipolar disorder. No person should stop valproate suddenly without specialist advice because severe relapse can occur. Valproate initiation below age 55 Starting valproate in any new patient younger than 55 generally requires independent agreement from two specialists. They must document that alternative treatments are ineffective or not tolerated. Compelling reasons can apply when reproductive risks do not affect the particular person. These requirements add to rather than replace pregnancy prevention measures. Valproate Pregnancy Prevention Programme Valproate must not be prescribed to a woman or girl able to become pregnant unless programme conditions are followed. The programme includes specialist review, clear risk counselling, effective pregnancy prevention and annual acknowledgement documentation. Pregnancy exposure causes major congenital malformations and frequent neurodevelopmental harm. A missed period, suspected pregnancy or pregnancy plan requires immediate specialist contact without abrupt self discontinuation. Valproate risks for male patients Current MHRA advice also recognises male infertility and possible reproductive risk around conception. Men taking valproate receive current family planning and precautionary contraception advice. New male patients younger than 55 still require two specialist approval before starting treatment. Treatment should be reviewed rather than stopped without specialist supervision. Antipsychotics as mood stabilising treatments Antipsychotics can treat acute mania, and some support long term mood stability or bipolar depression. Adverse effects can include sedation, movement symptoms, weight gain, diabetes risk and lipid changes. Baseline and continuing monitoring includes weight, pulse, blood pressure, glucose and lipids. Medicine choice depends on previous response, physical health and the dominant episode pattern. Lamotrigine Lamotrigine can help bipolar depression and prevention of future depressive episodes. It does not treat acute mania, and NICE advises against offering it for mania. The dose is increased slowly because rapid titration raises the risk of serious skin reactions. A new rash during dose escalation requires immediate medical advice. Psychological relapse prevention NICE recommends structured individual, group or family interventions designed specifically for bipolar disorder. These approaches provide education, mood monitoring, relapse planning and problem solving. They examine links between sleep, behaviour, stress and mood change. Psychological treatment complements medication and does not replace urgent care during severe mania. Relapse triggers and early warnings Sleep loss, shift work, childbirth, stress, alcohol, cannabis, stimulants and stopping medication can precipitate relapse. Personal warning signs may include reduced sleep need, faster speech, increased spending, social withdrawal or hopelessness. A written relapse plan identifies contacts, medication review, financial protection and crisis actions. Plans are updated after episodes because warning signs and preferences can change. Financial, sexual and safeguarding risks Mania can produce debt, gambling losses, unsafe contracts and other long term financial consequences. Sexual disinhibition can increase risks involving consent, exploitation, infection and unintended pregnancy. Safeguarding action may be required when children or vulnerable adults are affected. Risk management should remain proportionate and preserve autonomy wherever safely possible. Physical health Bipolar disorder is associated with increased cardiovascular and metabolic illness. Antipsychotics and some mood stabilisers can add weight, glucose, lipid or organ related risks. NICE recommends comprehensive physical health assessment at least annually. Physical healthcare is a core part of bipolar treatment rather than a separate optional concern. Pregnancy planning Pregnancy planning should begin before conception whenever possible. The specialist reviews relapse history, postpartum risk, medication safety, breastfeeding preferences and available support. Valproate is avoided under strict regulatory requirements, while lithium requires individual risk benefit planning. Abrupt medication cessation can cause severe relapse and should not occur without specialist advice. Postpartum mania and psychosis People with bipolar disorder have a high relapse risk after childbirth. Sudden sleeplessness, mania, confusion, hallucinations or delusions can indicate postpartum psychosis. This is a psychiatric emergency that can endanger the parent, baby or other people. Suspected postpartum psychosis requires immediate same day specialist assessment. Recovery Recovery can involve stable mood, restored relationships, meaningful activity and confidence recognising early warning signs. Some people continue experiencing sleep, anxiety or concentration difficulties between major episodes. Goals should reflect the person's values rather than only absence of hospital admission. Employment, education, family and social support can all contribute to sustained recovery. The central safety message Bipolar disorder involves distinct mood episodes rather than ordinary emotional variation. Psychosis, marked impairment or hospital need makes an elevated episode mania rather than hypomania. Medication requires careful selection and monitoring, particularly lithium and valproate. Psychotic mania, dangerous disinhibition, suicidal mixed states and postpartum psychosis require urgent specialist care.

Bipolar disorder is recognised through sustained episodes that differ clearly from usual functioning. Full mania causes marked impairment, hospitalisation or psychosis, while hypomania is shorter and less severe. Treatment requires specialist mood stabilising strategies, careful medicine monitoring and rapid escalation when safety is threatened.