Snapshot A 21-year-old woman is brought to the emergency room by a police officer. She was found wandering around the streets talking very rapidly about her plans to become the CEO of large companies such as Amazon. She did not resist being brought it but continued to delineate her goals, including traveling the world, establishing the world’s best charity, and rescuing all orphans. When her physician was able to reach a family member, they report that she had been acting this way for 2 weeks. She had previously had episodes of depression, but recently she has been sleeping only 1 hour a day, has been easily distracted, and talked very rapidly about her grand plans. Her only medication is an anti-depressant. Introduction Overview bipolar disorder is characterized by episodes of mania and depression treatment is mood stabilizers or atypical antipsychotics bipolar I at least 1 manic episode, with or without a hypomanic or depressive episode bipolar II hypomanic episode and depressive episode Epidemiology incidence lifelong prevalence range from 0.9-2.1% demographics mean age of onset is 21 years women often cycle through manic and depressive episodes more frequently risk factors other mood disorders Pathogenesis mechanism may be a genetic susceptibility for bipolar disorder may be atrophy in the brain Presentation Symptoms mood may normalize between episodes, and patient may be fully functional during this time using antidepressants may destabilize mood and trigger an episode of mania manic episodes (at least 1 week duration and causes marked impairment in function) or hypomanic episodes (at least 4 days duration and may not be severe enough to cause dysfunction) with 3 or more of the following grandiosity decreased sleeping excessive talking and pressures speech racing thoughts and ideas distractibility increased level of goal-focused activity at home, work, or sexually excessive pleasurable activities depressive episodes (2 weeks duration) with 5 or more of the following, including either depressed mood or loss of pleasure or interest in activities depressed mood loss of pleasure or interest in activities weight loss or gain or appetite loss or gain hypersomnia or insomnia psychomotor retardation or agitation loss of energy or fatigue feelings of worthlessness or excessive guilt decreased ability to concentrate or make decisions preoccupation with death or suicide either phase may have psychotic features Physical exam psychomotor agitation or depression Differential Cyclothymic disorder key distinguishing factors presents similarly but with milder symptoms and lasts 2 years or longer numerous periods of hypomanic symptoms that do not meet criteria for hypomania and depressive symptoms that do not meet criteria for a major depressive episode Treatment Non-medical psychotherapy indications may help decrease recurrence rates or help improve quality of life inpatient admission indications suicidal behavior or psychosis electroconvulsive therapy (ECT) indications refractory to medications Medical mood stabilizers indications first-line drugs lithium valproic acid carbamazepine lamotrigine atypical antipsychotics indications if there are features of psychosis drugs ziprasidone quetiapine risperidone aripiprazole Complications Increased risk of suicide