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Mental Health & Substance Use

Bipolar Disorder

A mood disorder characterized by recurrent episodes of significant disturbance in mood and activity levels, involving periods of elevated mood and energy (mania or hypomania) and periods of lowered mood and energy (depression). Recovery between episodes is typical.

Also known as: Manic-Depressive Illness, Bipolar Affective Disorder

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Referral and warning signs

When to refer

Refer ALL patients with suspected Bipolar Disorder to specialist (Mental Health specialist/Psychiatrist - HC3/HC4/H/RR) for: Diagnostic confirmation. Initiation and management of mood stabilizers (esp. Lithium, Valproate). Management of severe or treatment-resistant episodes. Management of bipolar depression. Assessment and management of comorbidities (substance use). Pregnant or planning pregnancy.

Red flags

  • Severe mania with psychosis, aggression, or poor judgment posing risk
  • Severe depression with high suicide risk or psychotic features
  • Rapid cycling (≥4 mood episodes per year)
  • Poor response to standard treatments
  • Suspicion of underlying organic cause for mood symptoms

Signs and symptoms

  • Manic Episode (Lasting ≥1 week, causing marked impairment/hospitalization, may have psychosis):
  • - Mood: Elevated (euphoric), expansive, or irritable.
  • - Energy/Activity: Markedly increased goal-directed activity or psychomotor agitation.
  • - Speech: Pressured, talkative.
  • - Thoughts: Flight of ideas, racing thoughts.
  • - Self-Esteem: Inflated, grandiosity.
  • - Sleep: Decreased need for sleep.
  • - Attention: Distractibility.
  • - Behavior: Increased involvement in activities with high potential for painful consequences (spending sprees, sexual indiscretions, foolish investments), impulsivity, increased sociability, increased libido.
  • - Psychotic features (delusions/hallucinations) may be present.
  • Hypomanic Episode (Similar to mania but less severe, lasting ≥4 days, noticeable change in functioning but not marked impairment/hospitalization, no psychosis).
  • Depressive Episode (Lasting ≥2 weeks):
  • - Symptoms identical to Major Depressive Episode (see MH002: low mood, anhedonia, fatigue, sleep/appetite changes, guilt, worthlessness, poor concentration, suicidal thoughts).
  • - Key differentiator is history of at least one manic or hypomanic episode.
  • Mixed Episode: Features of both mania/hypomania and depression occur simultaneously or alternate rapidly.

Risk factors

  • Genetic factors / Family history (strong influence).
  • Biological factors (neurotransmitter dysregulation).
  • Environmental factors (stressful life events can trigger episodes in predisposed individuals).
  • Substance abuse can trigger or worsen episodes.
  • Sleep deprivation.

Diagnosis

Clinical assessment

Diagnosis based on clinical interview establishing history of distinct mood episodes (mania/hypomania and potentially depression) meeting specific diagnostic criteria (e.g., DSM-5, ICD). CRUCIAL to ask about history of elevated mood/energy/activity when assessing a patient presenting with depression, to differentiate from unipolar depression. Assess severity, presence of psychosis, functional impairment, suicide risk, substance use.

Investigations

  • Usually diagnosed clinically.
  • Rule out organic causes of mania/psychosis: Toxicology screen (stimulants, alcohol withdrawal), Thyroid function tests (hyperthyroidism), Infections (HIV, syphilis, encephalitis), Autoimmune disorders, Brain imaging (if neurological signs or atypical presentation).

Diagnostic criteria

Requires history of at least one manic episode (for Bipolar I) or at least one hypomanic episode AND one major depressive episode (for Bipolar II). Cyclothymic disorder involves numerous periods of hypomanic and depressive symptoms not meeting full criteria for episodes.

Management

Non-pharmacological management

  • Psychoeducation (patient and family): Understanding the illness, recognizing early warning signs of relapse, importance of adherence, lifestyle management.
  • Psychotherapy (adjunctive): Cognitive Behavioral Therapy (CBT), Interpersonal and Social Rhythm Therapy (IPSRT), Family-Focused Therapy can help with coping, adherence, managing stressors, regulating routines.
  • Lifestyle Management: Maintaining regular sleep-wake cycles, managing stress, avoiding substance use.
  • Support groups.

Pharmacological treatment

  • Acute Manic/Hypomanic Episode:
  • - Goal: Rapid control of agitation, aggression, impulsivity, psychosis.
  • - Medications: Mood stabilizers AND/OR Antipsychotics.
  • - Antipsychotics (often used initially for rapid effect): Haloperidol (5-10mg PO/IM q12h, up to 30-40mg/d), Chlorpromazine (100-200mg PO/IM q8h, up to 300mg/d or higher), Trifluoperazine (5-10mg PO q12h, up to 40mg/d). Newer atypicals like Olanzapine (10-15mg/d, up to 20mg) or Risperidone (2-3mg/d, up to 6mg) also effective. (H/RR level for atypicals).
  • - Mood Stabilizers (start concurrently or when stable): Sodium Valproate (start 500mg/d, usual 1000-2000mg/d), Carbamazepine (start 200mg nocte, increase to 600-1000mg/d divided). Lithium (900-1800mg/d divided, requires level monitoring 0.8-1.2 mEq/L - RR level).
  • - Adjunctive Benzodiazepines: For severe agitation/insomnia short-term (e.g., Diazepam 5-10mg q12h).
  • - Discontinue antidepressants if patient was taking them.
  • Acute Bipolar Depressive Episode:
  • - Goal: Treat depressive symptoms without triggering mania/hypomania.
  • - Medications: Mood stabilizers are foundation. Options include Lithium, Valproate, Lamotrigine, or certain atypical antipsychotics (Quetiapine, Olanzapine+Fluoxetine combination).
  • - Antidepressants: Use with EXTREME CAUTION and ONLY in combination with a mood stabilizer, under specialist supervision, due to risk of inducing mania/rapid cycling. SSRIs (Fluoxetine, Sertraline) may be used.
  • Maintenance Treatment (Preventing Relapse):
  • - Goal: Prevent future manic and depressive episodes.
  • - Mood Stabilizers: Long-term treatment is essential. Lithium, Valproate, Carbamazepine, Lamotrigine are options. Choice depends on previous response, side effect profile, patient factors.
  • Follow specific Ugandan treatment algorithms/guidelines. Specialist initiation/supervision often required for mood stabilizers like Lithium, Valproate.
  • Treat Extrapyramidal Side Effects (EPS) from antipsychotics with Benzhexol 2mg PRN or scheduled.

Monitoring

Monitor mood symptoms (mania/depression scales if possible). Monitor for side effects of medications (Weight gain, sedation, metabolic effects with antipsychotics/valproate; tremor, thyroid/renal issues with Lithium; rash with Lamotrigine; EPS with antipsychotics). Monitor adherence. Monitor blood levels if using Lithium, Valproate, Carbamazepine. Assess suicide risk, especially during depressive or mixed episodes. Monitor for substance use.

Complications

  • High risk of recurrence
  • Suicide (risk significantly higher than general population)
  • Functional impairment (occupational, social)
  • Substance abuse
  • Medical comorbidities (cardiovascular, metabolic)
  • Cognitive impairment
  • Relationship difficulties

Prevention

  • Long-term maintenance treatment with mood stabilizers is key to preventing relapse.
  • Early recognition of warning signs and prompt intervention.
  • Lifestyle regularity (sleep, routines).
  • Avoidance of substance use.
  • Stress management.
  • Psychoeducation and adherence support.

Patient education

  • Explain bipolar disorder as a chronic, recurrent illness requiring long-term management.
  • Educate on different mood episodes (mania, depression) and early warning signs.
  • Stress critical importance of medication adherence for mood stabilizers.
  • Discuss potential side effects and need for monitoring (incl. blood tests for some meds).
  • Educate on lifestyle factors (sleep, stress, substance avoidance).
  • Involve family in education and support.
  • Provide information on support groups.

Uganda-specific notes

Bipolar disorder may be under-recognized, often misdiagnosed as recurrent depression or psychosis. Access to mood stabilizers like Lithium and Valproate, and necessary level monitoring, is often limited to higher-level facilities (H/RR). Antipsychotics (Haloperidol, Chlorpromazine) are more widely available for managing acute mania. Stigma is significant. Family involvement is crucial.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 9, Section 9.2.3

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