What are the three most important things you learned this week? What questions remain uppermost in your mind? Is there anything you did not understand?521BipolarDisorder

What are the three most important things you learned this week?

What questions remain uppermost in your mind?

Is there anything you did not understand?

Bipolar Disorder

Brian McCarthy, MSN, PMHNP-BC


Identify criteria for Bipolar Disorder as outlined in the DSM-V.

Identify diagnostic tools to help in the diagnosis of bipolar disorder.

Identify modalities for the treatment of mania.

Identify features of bipolar depression and its treatment

Identify features of mixed states and its treatment.

Identify feature of rapid cycling and its treatment.

What are your thoughts on bipolar disorder?

What is bipolar disorder and how do you understand it?

What gets in the way of understanding what it is?

What does “bipolar” actually mean—the key to understanding the disorder fully.


To be considered mania, the elevated, expansive, or irritable mood must last for at least one week and be present most of the day, nearly every day. To be considered hypomania, the mood must last at least four consecutive days and be present most of the day, almost every day.

DSM continued

During this period, three or more of the following symptoms must be present and represent a significant change from usual behavior:

Inflated self-esteem or grandiosity

Decreased need for sleep

Increased talkativeness

Racing thoughts

Distracted easily

Increase in goal-directed activity or psychomotor agitation

Engaging in activities that hold the potential for painful consequences, e.g., unrestrained buying sprees


The depressive side of bipolar disorder is characterized by a major depressive episode resulting in depressed mood or loss of interest or pleasure in life. The DSM-5 states that a person must experience five or more of the following symptoms in two weeks to be diagnosed with a major depressive episode:

Depressed mood most of the day, nearly every day

Loss of interest or pleasure in all, or almost all, activities

Significant weight loss or decrease or increase in appetite

Engaging in purposeless movements, such as pacing the room

Fatigue or loss of energy

Feelings of worthlessness or guilt

Diminished ability to think or concentrate, or indecisiveness

Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt

There is more than just the DSM

It is helpful to look at bipolar disorder as a spectrum

As such, there are many people who will not match up to the criteria.


The MINI 7.0

This screening tool is not free but it is not hard to get copies of and it is available for subscription.


Structured Clinical Interview for DSM Disorders.

Harvard Bipolar Index

Developed by Gary Sachs and others (Ghaemi) at Harvard. Validated by Aiken and Weisler in 2015. It looks at 5 domains:

Hypomania or mania

Age of onset of first mood symptoms

Illness course and other features generally only visible over time

Response to medications (antidepressants and mood stabilizers)

Family history of mood and substance use problems

In practice

See the actual index.

Why use these tools?

Greater reliability than just opinion.

They have been validated.

Why would we not use them?

Would you allow your pcp to diagnose you with diabetes without lab work? Just his/her opinion alone?

So you have a manic patient—what will you do?

What are the medications you know of that are first line treatments?

Most but not all of the atypicals.

Which ones would you avoid?

Anticonvulsants: Depakote, Carbamazepine.

Do you know how to dose?

Do you understand the lab work?


Gold standard

Dose at bedtime if possible

Do you know the lab values key for using lithium in mania?

Non-pharmacological options?


Dark Therapy

Classic dark therapy

Modified dark therapy with blue light filter glasses

Mania is resolved….now what?

What do you do with meds at this point?

Do you reduce?

Your patient has bipolar depression? Now what?

What are the meds with FDA approval for bipolar depression?





They aren’t working….now what?

What are your options?

Make sure the diagnosis is correct?

Think about the inflammatory theory of depression!

Inflammatory theory of depression/bipolar

Elevated levels of pro-inflammatory cytokines (TNF) in some patients

Variations in inflammatory markers depending on mood state (manic, euthymic, or depressed)

Positive correlation between elevated CRP and manic symptoms

Antidepressants with serotonergic effects had lower efficacy in patients with high inflammatory markers

Anti-inflammatory augmentation agents may help in patients with high inflammatory markers

Dopaminergic and glutamatergic agents may have better effects

Less Common Treatment Options.






T3 and T4




omega 3 fatty acids (O3FA)

n-acetylcysteine (NAC)

dextromethorphan and memantine




light therapy

Mechanisms of Action.

pramipexole: dopamine agonist

amantadine/memantine: dopamine agonist, NMDA receptor blocker

celecoxib: anti-inflammatory

minocycline plus aspirin: anti-inflammatory

statins: HMG-CoA reductase inhibitor, lowers CRP

O3FA: potentially anti-inflammatory


Light box: modulates circadian rhythm

T3 and T4: metabolic regulation

esketamine: NMDA receptor blocker

NAC: increases glutathione

TMS: modulates neural processing

riluzole: glutamate modulator


celecoxib, minocycline/aspirin, NAC, aspirin, O3FAs, statins

Note: must use PPI with celexicob

Aligns with inflammatory theory of depression

Check high sensitivity CRP

Mostly small research studies but promising results

May be especially useful for patients who have comorbidities that these drugs could also help with

O3FAs should have at least 1.5 times as much EPA as DHA for depression treatment

Dopaminergic agents

Pramipexole, amantadine, memantine

Dopamine agonist activity

May be used in conjunction with other medications.




T3 and T4


Non-pharmacological interventions.

MIND diet – combines Mediterranean and DASH (anti-inflammatory)

Light therapy

10,000 lux, at least 12”x17”, 30 mins per day


Blu-blocker glasses – use after 6pm

Dark therapy – used for manic symptoms

Mixed States.

a person may either be experiencing a manic episode with at least three symptoms of depression or on the contrary, a major depressive episode with at least three symptoms of mania.

Classic phrase “tired and wired.”

More susceptible to medication side effects.

Rapid Cycling

Four mood episodes in a calendar year

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