Bipolar disorders are chronic, recurrent mood disorders marked by episodes of mania or hypomania, usually alternating with major depressive episodes. Onset is typically in late adolescence or early adulthood. Heritability is among the highest of all psychiatric disorders. Proposed mechanisms include dysregulated monoamine signaling, disrupted circadian rhythms, and abnormal intracellular signaling; sleep loss, stimulants, antidepressants, and stress can trigger episodes.

DSM-5-TR episode definitions

Manic symptoms (mnemonic DIG FAST): Distractibility; Impulsive, risky activity (spending sprees, sexual indiscretion, reckless driving); Grandiosity or inflated self-esteem; Flight of ideas or racing thoughts; increased goal-directed Activity or psychomotor agitation; decreased need for Sleep (feels rested after 3 hours); Talkativeness or pressured speech.

Disorders

A full manic episode that emerges during antidepressant treatment and persists beyond the drug's physiological effect counts toward bipolar I.

Specifiers: with mixed features, with rapid cycling (≥ 4 mood episodes in 12 months), with psychotic features, with anxious distress, with peripartum onset, with seasonal pattern.

Mania

• Mood: euphoric, labile, or irritable; hostile when limits are set
• Speech and thought: pressured speech, flight of ideas, clang associations, grandiose (sometimes persecutory) delusions
• Behavior: hyperactivity, intrusiveness, poor judgment, overspending, sexual disinhibition, flamboyant dress, manipulation, splitting staff
• Physical: little sleep, not eating or drinking → dehydration, weight loss, exhaustion; injuries
• Poor insight — often denies illness

Bipolar depression — same features as MDD, often with hypersomnia and psychomotor slowing; suicide risk is high, especially during depressive or mixed episodes and after discharge.

Assess: safety (suicide, violence, recklessness), nutrition and hydration, sleep, substance use, finances and relationships affected, medication adherence, family history, early warning signs of past relapses.

Acute mania: lithium, valproate, or a second-generation antipsychotic (olanzapine, quetiapine, risperidone, aripiprazole, cariprazine), or haloperidol; severe cases may combine lithium or valproate with an antipsychotic. Benzodiazepines (e.g., lorazepam, clonazepam) are used short term as adjuncts for agitation and insomnia — not as mood stabilizers. Stop antidepressants during mania.

Bipolar depression: quetiapine, lurasidone, cariprazine, lumateperone, olanzapine-fluoxetine, lithium, or lamotrigine. Antidepressant monotherapy is avoided (risk of switching to mania or rapid cycling).

Maintenance: lithium (the long-standing first-line mood stabilizer and the drug with the best evidence for reducing suicide), valproate, lamotrigine (prevents depressive relapse; does not treat acute mania), or selected antipsychotics. ECT for severe, psychotic, or treatment-resistant episodes and in some pregnancies.

Lithium

Valproate (divalproex)

• Boxed warnings: hepatotoxicity (highest risk in children under 2 and in mitochondrial POLG disorders), pancreatitis (abdominal pain, vomiting), and fetal harm — neural tube defects and lower IQ. Avoid in people who can become pregnant unless no alternative works, with effective contraception and a documented discussion
• Other effects: thrombocytopenia, weight gain, tremor, hair loss, hyperammonemia (lethargy, confusion)
• Monitor liver tests and CBC with platelets (frequently in the first 6 months), and ammonia if mental status changes
• Level: epilepsy target about 50–100 mcg/mL (350–700 µmol/L); for mania, trough levels up to about 125 mcg/mL (870 µmol/L) are used per labeling
• Valproate doubles lamotrigine levels — lamotrigine doses must be reduced

Lamotrigine — serious rash (Stevens-Johnson syndrome/toxic epidermal necrolysis); slow titration; stop and report any rash. If lamotrigine has been stopped for about 5 days or more (≥ 5 half-lives), restart the titration schedule — do not resume the prior dose. Estrogen-containing contraceptives lower lamotrigine levels; rash risk is higher with valproate co-therapy (lamotrigine dose is halved).

Class warning: all antiseizure mood stabilizers (valproate, lamotrigine, carbamazepine) carry a warning for increased suicidal thoughts and behavior — monitor mood.

Carbamazepine — agranulocytosis and aplastic anemia, hyponatremia, SJS/TEN (HLA-B*15:02), enzyme induction (lowers hormonal contraceptive and other drug levels), teratogenic.

Second-generation antipsychotics — metabolic effects, EPS, sedation, orthostatic hypotension; boxed warning for older adults with dementia-related psychosis (see schizophrenia topic).

Psychosocial — psychoeducation, family-focused therapy, interpersonal and social rhythm therapy (regular sleep and daily routines), CBT, relapse-prevention planning.

Listed in priority order.

1. Safety
   • Assess suicide risk directly in depressive and mixed states; remove hazards
   • Mania with aggression: approach calmly, keep a safe distance, separate the client from others, use brief firm statements; offer PRN medication; seclusion or restraint only as a last resort per policy
   • Protect from risky behavior: supervise finances, phone use, and sexual behavior; protect dignity (clothing)
2. Reduce stimulation — quiet, low-stimulus area or single room; limit group activities, noise, and visitors during acute mania; redirect to a quiet space and a structured, solitary, noncompetitive activity (walking, writing, simple tasks) rather than competitive or vigorous games
3. Physiological needs
   • High-calorie, high-protein finger foods and portable drinks the client can take while moving; weigh daily; monitor intake and output
   • Promote rest and sleep; reduce evening stimulation
4. Communication and limit setting
   • Short, clear, concrete statements; do not argue with grandiosity; redirect
   • Consistent limits enforced by all staff to prevent manipulation and splitting; state consequences calmly
5. Medication safety
   • Check lithium level timing (trough), signs of toxicity, fluid and sodium intake, and kidney and thyroid results
   • Hold the dose and notify for vomiting, diarrhea, coarse tremor, ataxia, or confusion
6. Maintenance phase — adherence, self-monitoring of mood and sleep, early warning signs, stable routines; family psychoeducation aims to understand and support, not to control or police the client

• Take mood stabilizers every day, including when well; most relapses follow stopping medication
• Lithium:
  • Keep sodium intake consistent and drink about 2–3 L of fluid daily unless told otherwise
  • Replace fluids during heat, exercise, or sweating
  • If you have vomiting, diarrhea, or fever, contact your prescriber promptly — you may be told to hold doses until you can eat and drink
  • Avoid NSAIDs (ibuprofen, naproxen) and ask before starting any diuretic or blood pressure drug
  • Keep level appointments and delay the morning dose until after the blood draw
  • Know early toxicity signs: vomiting, diarrhea, coarse shaking, unsteadiness, slurred speech
  • Increased urination and thirst are common — report if severe
• Valproate: report abdominal pain, jaundice, easy bruising, or confusion; use effective contraception
• Lamotrigine: report any rash immediately
• Protect sleep, avoid alcohol and stimulants, keep a mood and sleep chart
• Plan pregnancy with your prescriber before conception

• Bipolar I = at least one manic episode; bipolar II = hypomania + major depression, never mania
• Mania ≥ 1 week (or any duration if hospitalized); hypomania ≥ 4 days, no psychosis or hospitalization
• Mania symptoms: DIG FAST — decreased need for sleep, flight of ideas, grandiosity, pressured speech, risky activity
• Acute mania nursing: safety, low stimulation, finger foods, consistent limits, solitary noncompetitive activity
• Lithium level 0.6–1.2 mEq/L, trough 12 hours after dose; toxicity usually above 1.5
• Lithium toxicity early signs: vomiting, diarrhea, coarse tremor, ataxia
• NSAIDs, thiazides, ACE inhibitors, dehydration, and low sodium raise lithium levels
• Lithium long term: hypothyroidism, nephrogenic DI, kidney damage
• Valproate: hepatotoxicity, pancreatitis, neural tube defects, thrombocytopenia
• Lamotrigine: rash (SJS); valproate doubles its level
• Benzodiazepines: short-term adjunct for agitation and insomnia only
• Avoid antidepressant monotherapy in bipolar depression