ICD-116A60	BIPOLAR TYPE I DISORDER Bipolar type I disorder
ICD-10F31	Bipolar affective disorder
DSM-5-TRF31.1x	Bipolar I Disorder, Current or Most Recent Episode Manic

1. Definition and nosology

Bipolar disorder Type I (ICD-11: 6A60; DSM-5-TR: F31.1x) — a recurrent disorder characterized by at least one manic episode, often alternating with depressive and/or hypomanic episodes. The presence of a manic episode is sufficient for diagnosis — a depressive episode is not required.

2. History

• Falret J.P. (1854) — Circular insanity; Baillarger J. (1854) — “folie à double forme”.
• Kraepelin E. (1899) — Manic-depressive insanity — distinct from schizophrenia (dementia praecox).
• Leonhard K. (1957) — first distinction between unipolar and bipolar disorders.
• DSM-III (1980) — term “Bipolar Disorder”.
• DSM-IV / DSM-5 (2013) / ICD-11 (2019) — Distinction between Type I (full manic episode) and Type II (hypomanic + major depressive).

3. Epidemiology

• Lifetime prevalence Type I: ~0.6–1% (Merikangas K.R. et al. Arch Gen Psychiatry 2011, WMH).
• Gender: approximately equal.
• Onset: mid-20s to 25 years; earlier with a family history.
• Suicide risk: lifetime 6–7%; highest in youth and in the first years.
• Comorbidity: anxiety disorders 60%, substance use 40%, ADHD, personality disorders.
• Mortality is 2 times higher compared to the population — cardiovascular, suicide.

4. Aetiology and pathogenesis

• Heritability 60–85% (Smoller J.W., Finn C.T. Am J Med Genet C Semin Med Genet 2003 twin meta-analysis).
• GWAS — 60+ risk loci (Mullins N. et al. Nat Genet 2021).
• Schizophrenia with extensive genetic overlap (Cross-Disorder Group 2013).
• Neurobiological — monoaminergic (dopamine, serotonin, norepinephrine) dysregulation; circadian rhythm disruption; second messenger (PI/cAMP) system impairment; mitochondrial dysfunction.
• Risk factors — childhood trauma, stress, sleep disturbance, cannabis, antidepressant induction (in bipolar predisposition).

5. Clinical features

5.1 Manic episode

• Abnormally elevated or irritable mood + increased energy ≥ 7 days (or any duration requiring hospitalization).
• ≥ 3 symptoms from the following (≥ 4 in irritable mood): inflated self-esteem, decreased need for sleep, pressured speech, flight of ideas, distractibility, increase in goal-directed activity, risky behaviors.
• Functional impairment or requirement for hospitalization or psychotic features.

5.2 Major depressive episode (in bipolar context)

• Low mood or anhedonia + ≥ 5 symptoms × 2 weeks (DSM-5-TR).
• Bipolar depressive episode with atypical features (hypersomnia, hyperphagia, leaden paralysis) is more common — similar to Type II.

5.3 Mixed features

DSM-5-TR — subtype abolished — as a specifier: ≥3 depressive symptoms during a manic episode or ≥3 manic symptoms during a depressive episode.

5.4 Rapid cycling

≥4 episodes within 12 months; poor prognostic marker.

6. Diagnosis

6.1 Unified diagnostic criteria (DSM-5-TR · ICD-11 consensus points)

A. At least one manic episode (the above criteria).

B. Manic and depressive episodes are not better explained by schizoaffective disorder, schizophrenia, or another psychotic disorder.

Depressive and hypomanic episodes are not required for Type I diagnosis, but are typically present

6.2 Source-specific clarifications

• DSM-5-TR: Mixed features specifier (DSM-IV mixed episode abolished); increased energy added as a criterion for manic episode (DSM-IV only mood).
• ICD-11 (6A60): Number of manic episodes and current episode type subqualifiers; rapid cycling as a qualifier.
• NICE CG185: diagnosis supported by structured interview and family information; antidepressant-triggered hypomanic/manic episode leads to bipolar diagnosis (in DSM-5-TR with criterion B qualifier).

6.3 Diagnostic algorithm

1. Clinical interview + relative/friend information — manic and hypomanic episodes are more easily recognized by family members.
2. Structured interview (SCID-5, MINI).
3. YMRS (Young Mania Rating Scale), HAM-D / MADRS.
4. MDQ (Mood Disorder Questionnaire) or HCL-32 — bipolar screening (self-report).
5. Medical examination + laboratory (thyroid, liver, kidney, glucose, toxicological); specific tests before lithium initiation.
6. Brain MRI — first episode psychosis or atypical context.
7. Comorbidity and suicide risk (C-SSRS).

6.4 Differential diagnosis

7. Examination and assessment

• YMRS, HAM-D / MADRS, MDQ, HCL-32, C-SSRS.
• Pre-lithium: complete blood count, creatinine, TSH, calcium, EKG, pregnancy test.
• Pre-valproate: complete blood count, liver function, pregnancy test (for women of childbearing potential — valproate is strictly not recommended).
• Before carbamazepine: complete blood count, liver, sodium.
• Brain MRI — first psychotic episode.

8. Treatment

8.1 General principles (NICE CG185 · CANMAT/ISBD 2018 · APA · WFSBP consensus)

1. Acute manic episode: Antipsychotic (olanzapine, risperidone, quetiapine, aripiprazole, asenapine) ± mood stabilizer (lithium, valproate). Lorazepam adjunct in acute agitation.
2. Acute bipolar depressive episode: quetiapine or lurasidone (FDA approval), olanzapine/fluoxetine combination (Symbyax); lithium or lamotrigine adjunctive therapy. Antidepressant monotherapy is contraindicated — Manic switch and rapid cycling risk.
3. Maintenance: Lithium first-line — suicide reduction effect (Cipriani A. BMJ 2013); valproate, quetiapine, lamotrigine (especially with dominant depressive component), olanzapine alternatives.
4. Refractory: clozapine; ECT.
5. Rapid cycling — stop antidepressant; combination of lithium and valproate.
6. Psychosocial intervention: Psychoeducation, CBT for bipolar, IPSRT (Interpersonal and Social Rhythm Therapy — Frank E.), family-focused therapy (Miklowitz D.).
7. Adherence and side effect monitoring — Lithium: TSH, creatinine, calcium every 6 months; valproate: hepatic and hematologic.
8. Women of childbearing age: valproate absolute contraindication (neural tube defects 1–2%, major congenital malformations overall ~10%, autism and IQ deficit); lamotrigine and quetiapine relatively safe.

8.2 Pharmacotherapy (Table)

8.3 Source-Specific Clarifications

• CANMAT/ISBD 2018 (Yatham L.N. et al. Bipolar Disord 2018): First-line for manic — lithium, valproate, quetiapine, aripiprazole, asenapine, paliperidone, risperidone; for bipolar depressive — quetiapine, lurasidone (monotherapy or adjunct with lithium/valproate).
• NICE CG185: Lithium is first-line maintenance; an antidepressant only together with a mood stabilizer.
• Cipriani A. et al. BMJ 2013 meta-analysis: Lithium significantly reduces suicide rates (superior to other mood stabilizers).
• EMA and FDA warnings: valproate in women of childbearing age — neural tube defects, autism, IQ decrease.

Treatment methods

1. Lithium — Gold standard in bipolar disorder; reduces suicide; initial parameters creatinine, TSH, calcium, EKG; therapeutic level 0.6–1.0 mEq/L; toxicity > 1.5 mEq/L. Cipriani BMJ 2013.
2. CBT adapted for bipolar disorder — Psychoeducation, early marker recognition, behavioral activation, compliance support. Lam D.H. et al. Arch Gen Psychiatry 2003 RCT.
3. Interpersonal and Social Rhythm Therapy (IPSRT — Interpersonal and Social Rhythm Therapy) — Frank (Frank E.) — Circadian rhythm and interpersonal stress management in bipolar disorder. Frank E. et al. Arch Gen Psychiatry 2005 RCT — reduction of relapse in maintenance phase.
4. Family-Focused Therapy (FFT) — Miklowitz D. — Patient + family jointly; psychoeducation, communication, problem-solving. Miklowitz D.J. et al. Arch Gen Psychiatry 2003;60(9):904–912.
5. Young Mania Rating Scale (YMRS) — 11 items, manic episode severity: initial indicators and monitoring.
6. Mood Disorder Questionnaire (MDQ — Mood Disorder Questionnaire) — Hirschfeld (Hirschfeld R.M.) — 13-item self-assessment for bipolar screening.
7. ECT — In refractory manic or depressive episode, with mixed features, suicidal risk, a safe alternative in pregnancy. NICE TA59.

9. Prognosis

• Episodic course; relapse 80–90% (untreated); significant reduction with maintenance pharmacotherapy.
• Suicide risk high (6–7% lifetime); particularly in the first years.
• Increased cardiovascular mortality (metabolic syndrome).
• Functional recovery moderate — the majority of patients experience significant social and occupational impairment.
• Monitoring — mood scales, suicide risk, metabolic indicators, lithium level, compliance.

10. Myths and misconceptions

Myth 1: “Bipolar disorder is simple mood swings — everyone has them”

Clinical logic: Bipolar manic episode requires both duration (≥7 days) and functional impairment; it is a distinct clinical condition from daily mood fluctuations. Manic episode may require psychotic features and hospitalization. Evidence: Merikangas Arch Gen Psychiatry 2011.

Myth 2: “Bad parenting causes bipolar disorder”

Evidence: heritability 60–85%; parental experience not etiology. Smoller & Finn 2003.

Myth 3: “Bipolar patient is creative or a ‘marker of genius’”

Evidence: Some studies show moderate increase in bipolar prevalence in creative professions (Andreasen N.C. reviews), but most patients experience functional impairment; ‘duality’ explanation leads to romanticization and treatment refusal.

Myth 4: “Antidepressants always help a bipolar patient”

Evidence: NICE CG185, CANMAT — antidepressant monotherapy in bipolar disorder is contraindicated; risk of manic switch and rapid cycling.

Myth 5: “Lithium is ‘outdated’ or dangerous — atypical antipsychotic should be first-line”

Evidence: Cipriani BMJ 2013 — lithium reduces suicide significantly more than other mood stabilizers; NICE CG185 and CANMAT 2018 — first-line in maintenance.

Myth 6: “The patient can ‘volitionally’ control their mood”

Evidence: bipolar episode is neurobiological impairment; not voluntarily controllable; requires pharmacotherapy or ECT.

Myth 7: Disinterested observation is sufficient — it will resolve on its own

Evidence: Untreated episodes — long-term functional impairment, cardiovascular mortality, suicide (6–7% lifetime).

Myth 8: Herbal preparations (St John's Wort, valerian) or omega-3 replace mood stabilizers

Evidence: St. John's Wort reduces the levels of mood stabilizers through cytochrome P450 induction and may trigger a manic switch; omega-3 has a mild adjunct effect, it is not the primary treatment.

Myth 9: “Cannabis is a mood stabilizer”

Evidence: Cannabis worsens bipolar course, increases psychosis risk, reduces compliance.

Myth 10: “Mood stabilizer must be completely discontinued during pregnancy”

Evidence: Treatment discontinuation increases the risk of recurrence by 5-fold (Viguera A.C. et al. Am J Psychiatry 2007). Valproate is contraindicated, but lamotrigine and quetiapine are relatively safe; individual balance should be assessed (NICE CG192).

11. Sources

1. WHO. ICD-11. 6A60 Bipolar type I disorder. 2024.
2. APA. DSM-5-TR. 2022.
3. NICE CG185. Bipolar disorder: assessment and management. 2014/2020.
4. Yatham L.N., Kennedy S.H., Parikh S.V. et al. CANMAT and ISBD 2018 guidelines for the management of patients with bipolar disorder. Bipolar Disord 2018;20(2):97–170.
5. Cipriani A., Hawton K., Stockton S., Geddes J.R. Lithium in the prevention of suicide in mood disorders: updated systematic review and meta-analysis. BMJ 2013;346:f3646.
6. Merikangas K.R., Jin R., He J.P. et al. Prevalence and correlates of bipolar spectrum disorder in the world mental health survey initiative. Arch Gen Psychiatry 2011;68(3):241–251.
7. Smoller J.W., Finn C.T. Family, twin, and adoption studies of bipolar disorder. Am J Med Genet C Semin Med Genet 2003;123C(1):48–58.
8. Mullins N. et al. Genome-wide association study of more than 40,000 bipolar disorder cases. Nat Genet 2021;53(6):817–829.
9. Frank E., Kupfer D.J., Thase M.E. et al. Two-year outcomes for interpersonal and social rhythm therapy in individuals with bipolar I disorder. Arch Gen Psychiatry 2005;62(9):996–1004.
10. Miklowitz D.J., George E.L., Richards J.A. et al. A randomized study of family-focused psychoeducation in bipolar disorder. Arch Gen Psychiatry 2003;60(9):904–912.
11. Viguera A.C., Whitfield T., Baldessarini R.J. et al. Risk of recurrence in women with bipolar disorder during pregnancy: prospective study of mood stabilizer discontinuation. Am J Psychiatry 2007;164(12):1817–1824.
12. Hirschfeld R.M., Williams J.B., Spitzer R.L. et al. Development and validation of a screening instrument for bipolar spectrum disorder: the Mood Disorder Questionnaire. Am J Psychiatry 2000;157(11):1873–1875.
13. Andreasen N.C. Creativity and mental illness: prevalence rates in writers and their first-degree relatives. Am J Psychiatry 1987;144(10):1288–1292.