Bipolar disorder: mania and hypomania ✅

Related Subjects: |Psychiatric Emergencies |Depression |Bipolar disorder: mania and hypomania |Young Mania Rating Scale |Schizophrenia |Suicide |Acute Psychosis |Delusions |General Anxiety Disorder |Obsessive-Compulsive disorder |Wernicke Korsakoff Syndrome |Medically Unexplained symptoms |Postpartum/Postnatal Depression |Postpartum / Postnatal Psychosis |Eating disorders in Children

🧠 Bipolar disorder is characterised by episodes of mania or hypomania, often alternating with depressive episodes. Mania is a psychiatric emergency when there is psychosis, dangerous impulsivity, severe insomnia, aggression, self-neglect, safeguarding risk or loss of insight.

🧠 About

• Hypomania = elevated or irritable mood with increased energy, but without psychosis or marked social/occupational impairment.
• Mania = more severe mood elevation or irritability with marked impairment, psychosis, dangerous impulsivity, hospital admission or loss of contact with reality.
• Bipolar I disorder involves at least one manic episode.
• Bipolar II disorder involves hypomanic episodes plus depressive episodes, but no full manic episode.
• Always consider secondary mania, especially with first presentation later in life: steroids, antidepressants, stimulants, substances, hyperthyroidism, infection, delirium or neurological disease.

🔎 Clinical Features

• Persistently elated, expansive or irritable mood.
• Increased energy and increased goal-directed activity.
• Reduced need for sleep without fatigue.
• Pressured speech, racing thoughts or flight of ideas.
• Disinhibition: impulsive spending, substance misuse, sexual risk-taking, reckless driving or unsafe decisions.
• Grandiosity: inflated self-esteem, unrealistic plans or grandiose delusions.
• Distractibility and poor concentration.
• Psychotic features may occur in mania, but should not occur in hypomania.
• Poor insight, impaired judgement and loss of function suggest mania rather than hypomania.

💊 Mania / Hypomania and Antidepressants

• Antidepressants can precipitate mania or hypomania, especially in undiagnosed bipolar disorder.
• Before starting an antidepressant, screen for previous mania/hypomania: reduced need for sleep, increased energy, grandiosity, pressured speech, overspending, disinhibition or risk-taking.
• If mania/hypomania develops on antidepressant monotherapy, consider stopping the antidepressant and offer an antipsychotic.
• If mania/hypomania develops while taking an antidepressant plus a mood stabiliser, consider stopping the antidepressant and optimise bipolar treatment.
• Do not use antidepressant monotherapy in suspected bipolar depression.

🧠 Prescribing pearl: A bipolar screen before prescribing an SSRI is not optional trivia. Antidepressant monotherapy may switch bipolar depression into mania or worsen rapid cycling.

📊 Young Mania Rating Scale (YMRS)

• The Young Mania Rating Scale is an 11-item clinician-rated scale used to assess severity of mania.
• It is useful for baseline assessment and monitoring response to treatment.
• It scores symptoms such as elevated mood, increased activity, sexual interest, sleep, irritability, speech, thought disorder, disruptive behaviour, appearance and insight. Total score range: 0-60.

🧠 YMRS pearl: The YMRS helps measure manic symptom burden, but risk drives urgency. A patient with psychosis, violence, extreme disinhibition, severe insomnia, self-neglect or safeguarding concerns may need urgent admission even if a formal score has not yet been completed.

🚨 Acute Mania / Hypomania Management

• Assess risk urgently: suicide, violence, exploitation, sexual risk, finances, driving, safeguarding, psychosis, self-neglect and capacity.
• Check for secondary causes: drugs, alcohol, stimulants, antidepressants, steroids, thyroid disease, infection, delirium and neurological disease.
• Hospital admission may be needed if there is psychosis, severe behavioural disturbance, high risk, poor insight or inability to maintain safety.
• Detention under the Mental Health Act 1983 may be required if the patient refuses necessary admission and risks are high.
• If not already on treatment, NICE recommends offering haloperidol, olanzapine, quetiapine or risperidone.
• If response is inadequate, specialist teams may switch antipsychotic or add/optimise lithium.
• Valproate may be considered only with appropriate restrictions and specialist oversight.
• Lorazepam may be used short term for severe agitation or insomnia according to local rapid tranquillisation policy.

💊 Acute Mania: Common Medication Options

📅 Maintenance / Relapse Prevention

• Lithium is a key long-term mood stabiliser and has evidence for reducing relapse and suicide risk.
• Once stable, lithium levels are commonly maintained around 0.6-0.8 mmol/L; higher levels may be used in selected relapse-prone patients under specialist advice.
• Monitor lithium levels every 3-6 months and check U&E/eGFR, TFTs, calcium and weight/BMI at least every 6 months, or more often if high risk.
• Valproate is effective for mania prevention but has major teratogenic and neurodevelopmental risks; use only with strict MHRA restrictions and specialist oversight.
• Lamotrigine is more useful for bipolar depression relapse prevention than acute mania.
• Quetiapine or other antipsychotics may be used for maintenance in selected patients, balancing relapse prevention against metabolic and extrapyramidal adverse effects.
• Relapse prevention should include psychoeducation, sleep/circadian stability, early-warning signs, substance-use reduction and a written crisis plan.

⚕️ Secondary Mania: Do Not Miss

• Drugs: corticosteroids, antidepressants, stimulants, dopaminergic drugs, recreational drugs.
• Endocrine: hyperthyroidism, Cushing syndrome.
• Neurological: stroke, tumour, epilepsy, head injury, dementia, encephalitis.
• Medical: infection, delirium, metabolic disturbance, sleep deprivation.
• First manic presentation in later life should prompt a careful medical, medication and neurological review.

🧪 Suggested Initial Physical Screen

• Observations, hydration, sleep, nutrition and mental state examination.
• Medication review, alcohol/recreational drug history and collateral history.
• Bloods: FBC, U&E/eGFR, LFT, TFT, calcium, glucose/HbA1c, lipids if starting antipsychotic.
• Pregnancy test where relevant before mood stabilisers or antipsychotics.
• ECG if cardiac disease, QT risk, older age, electrolyte disturbance or antipsychotic use.
• Consider CT/MRI brain, infection screen or toxicology if atypical, late-onset or delirium-like presentation.

Cases - Bipolar Mania / Hypomania

• Case 1 - Classic acute mania 🔥: A 26-year-old man has 1 week of reduced need for sleep, pressured speech, flight of ideas and grandiose plans to “start a global company overnight.” He is distractible and spending large amounts online. Diagnosis: manic episode, consistent with bipolar I disorder. Management: risk assessment, likely admission, antipsychotic such as olanzapine/haloperidol/quetiapine/risperidone, and specialist consideration of mood stabiliser.
• Case 2 - Mania with psychosis 🧠: A 34-year-old woman presents with elevated mood, irritability and increased energy. She hears voices telling her she is chosen to be “queen of the world” and has grandiose delusions. Diagnosis: mania with psychotic features. Management: urgent psychiatric assessment, antipsychotic treatment, consideration of mood stabiliser and inpatient care.
• Case 3 - Antidepressant-associated switch 💊: A 29-year-old treated with an SSRI for depression develops reduced sleep, increased energy, pressured speech and reckless spending. Diagnosis: possible antidepressant-induced hypomania/mania revealing bipolar vulnerability. Management: consider stopping antidepressant, assess risk and treat manic symptoms; avoid antidepressant monotherapy.
• Case 4 - Secondary mania ⚕️: A 58-year-old man with no psychiatric history develops hyperactivity, pressured speech and irritability after high-dose prednisolone for temporal arteritis. Diagnosis: steroid-induced mania. Management: reduce steroid dose if clinically safe, assess medical risks and use antipsychotic treatment if needed.

Teaching Point 🩺: Mania is not simply “being happy”; it is a state of increased energy, reduced need for sleep, disinhibition and impaired judgement. Always ask about past hypomania before prescribing antidepressants, and always consider secondary causes when mania presents for the first time, especially in later life.

📚 References

• NICE CG185: Bipolar disorder - assessment and management
• NICE: Treatment for mania or hypomania
• NICE CKS: Bipolar disorder
• NICE CKS: Lithium prescribing information
• MHRA/GOV.UK: Valproate reproductive risks
• Specialist Pharmacy Service: Lithium monitoring