Bipolar Disorder Pharmacotherapy

Introduction & goals of pharmacotherapy

• Bipolar disorder — a chronic mood (affective) disorder with cyclically alternating manic and depressive phases. Mania — elated/irritable mood, reduced sleep, hyperactivity, flight of ideas, sometimes reckless behaviour and loss of contact with reality; depression — sadness, anhedonia, guilt, psychomotor slowing, self-destructive ideation.
• Two categories — Bipolar I — full manic episodes (± depression); Bipolar II — hypomania alternating with major depression but no full mania. Mixed features (concurrent manic + depressive) and rapid cycling (frequent recurrence; responds poorly to lithium) are difficult sub-phenotypes.
• Burden — after one manic episode the lifetime risk of recurrence is 80–90%; patients spend much of their time depressed (BP-I ~32%, BP-II ~50%), and ~15% eventually die by suicide — driving lithium's central role (the mood stabiliser with the most robust anti-suicide data).
• Goals — (i) rapid control of acute mania; (ii) treatment of bipolar depression; (iii) maintenance/prophylaxis to prevent relapse of both poles and reduce suicide. Treatment is empirical and symptom-oriented — not curative.