Bipolar Disorder

The manic patient feels invincible, hasn't slept in four days, and just gave away their savings — but they'll insist nothing is wrong. Recognizing mania means looking past the euphoria.

A manic episode requires at least 7 consecutive days (or any duration if hospitalization is needed) of abnormally elevated, expansive, or irritable mood plus increased goal-directed energy, with at least 3 of these features (4 if mood is only irritable): decreased need for sleep (feels rested after 2–3 hours), pressured speech, flight of ideas, distractibility, grandiosity, psychomotor agitation or increased goal-directed activity, and excessive involvement in risky behaviors (spending sprees, sexual indiscretion). Mania differs from hypomania by severity: mania causes marked functional impairment or may include psychotic features such as grandiose delusions. The patient typically lacks insight — they feel better than ever (or, if irritable, may feel others are the problem) and resist treatment. Priority nursing concerns during acute mania are safety (impulsive behavior, aggression, exhaustion), nutrition and hydration (too distracted to eat or drink adequately), and sleep deprivation. The environment should be low-stimulation: dim lights, reduced noise, limited group interactions. Offer high-calorie finger foods and fluids the patient can consume while moving. Set firm, consistent limits on unsafe behavior without being punitive.

Key Distinctions

Don't confuse mania (≥7 days, severe impairment, possible psychosis) with hypomania (≥4 days, noticeable change but no psychosis and no hospitalization). Students often mistake the euphoric, talkative patient as 'doing well' — elevated mood in mania is pathological, not recovery. Flight of ideas (loosely connected topics) differs from loose associations (no logical connection), which suggests a psychotic disorder.

Clinical Pearl

DIG FAST — Distractibility, Indiscretion, Grandiosity, Flight of ideas, Activity increase, Sleep deficit, Talkativeness. If the patient checks most of these boxes, think mania.

Depression & Maintenance

Bipolar depression is the phase patients spend the most time in, yet it carries unique treatment constraints. The cornerstone difference: antidepressant monotherapy is contraindicated because it can trigger a manic switch or rapid cycling. Instead, mood stabilizers form the foundation. Lithium (therapeutic range 0.6–1.2 mEq/L for maintenance) is a key agent for both bipolar depression and long-term relapse prevention. Lamotrigine is particularly effective for preventing bipolar depressive episodes and is titrated slowly to avoid Stevens-Johnson syndrome. If an antidepressant is used at all, it must be paired with a mood stabilizer. Quetiapine (an atypical antipsychotic) is also FDA-approved for bipolar depression. Maintenance therapy is lifelong — discontinuation dramatically increases relapse risk. Nursing priorities during the depressive phase include monitoring for psychomotor retardation, social withdrawal, hypersomnia, hopelessness, and medication adherence. Patients often stop medications when they feel stable, so ongoing education about the chronic relapsing nature of bipolar disorder is essential. Lithium monitoring includes renal function, thyroid function, and hydration status, since dehydration and sodium depletion raise lithium levels toward toxicity.

Key Distinctions

Don't confuse bipolar depression treatment with unipolar depression treatment — SSRIs alone are appropriate for MDD but dangerous in bipolar disorder. Students mix up lithium maintenance range (0.6–1.2 mEq/L) with acute mania range (1.0–1.5 mEq/L). Lamotrigine prevents depressive episodes; it does not treat acute mania — students often assume all mood stabilizers work the same way in both phases.

Clinical Pearl

Think "no antidepressant flies solo" — in bipolar depression, an antidepressant without a mood stabilizer is like removing the guardrails on a mountain road.