Tag Archives: bipolar disorder

Bipolar I Disorder: Most Recent Episode Manic Diagnosis

Bipolar I Disorder: Most Recent Episode Manic Diagnosis: Most Essential Features

In order to have a bipolar I disorder diagnosis, it is absolutely essential to have at least one episode of mania. This manic episode will need to last at least a week, almost every day with symptoms present most of the time. During this period of mania, you will experience a high level of energy along with an elevated, irritable or expansive mood. Many individuals also experience an increased level of goal-directed behaviors. These behaviors need to be much more pronounced than normal, usual behaviors. If the mood is only irritable you may experience the following symptoms: the need for sleep; pressured speech or abnormally talkative; flight of ideas and racing thoughts; inflated sense of self-esteem or grandiosity; difficulty concentrating and easily distracted; major increase in psychomotor agitation or goal-directed activity associated with work, social, sexually related and possibly a significant increase in behaviors that could be riskier and result in severe negative consequences.

Additionally, individuals experiencing bipolar I disorder frequently also have histories of major depressive and hypomanic episodes, but it is not essential. Although many people believe that bipolar I disorder involves rapid mood swings, frequently that does not occur. Changes from mania to depression or hypomania could go on for weeks, months or longer. They may resolve to be followed by additional episodes at a later point in time.


Bipolar I Disorder: Most Recent Episode Manic-Special Considerations:

Bipolar I most recent episode manic have some special concerns in that it can be an extremely dangerous mood at times. Some research has found that as many as 25% to 50% of individuals who have a diagnosis of bipolar I disorder eventually attempt suicide.

Individuals experiencing a manic episode often become involved in very risky behavior. Some of these experiences can even be life-threatening. Clinicians working with patients having bipolar I mood episodes need to be very aware of the risks involved in that they need to make it a part of their work with clients to make risk assessments and have crisis planning.

The healthcare costs associated with bipolar I disorder are very high. Some research has found that bipolar I disorder results in three times higher cost than among other individuals because of the increased level of hospitalization, visits to doctors and the expense of medications.

Bipolar I Disorder: Most Recent Episode Manic-Psychological Treatment and Medications

Bipolar I disorder requires lifelong management of symptoms. Fortunately, there are effective treatments that can help you or your loved ones to have a relatively normal life. Medications are available to stabilize mood and psychosocial treatments are available. Research has found that some of the more effective treatments include the combination of medications along with psychological interventions. Some of the more effective psychological interventions for the treatment of bipolar I disorder include cognitive behavioral therapy, psychoeducation, family-focused therapy, and interpersonal social rhythm therapy.

The specific criteria for bipolar I disorder most recent episode manic follow:

Basic Bipolar I Disorder Diagnosis Criteria

A. Criteria have been met for at least one manic episode.
B. The occurrence of the manic and major depressive episode or episodes is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other schizophrenia spectrum and other psychotic disorders.

Manic Episode;

A. A distinct period of abnormal and persistent, elevated, expansive or irritable mood, and abnormal and persistent increased goal directed activity or energy. This must last for at least a week and be present most of the day, nearly every day.

B. During this period of mood disturbance with increased energy or activity, three (or more) of the following symptoms (except for if the mood is only irritable) and are to a significant degree and must be a noticeable change from your usual behavior.

1. Inflated self-esteem or sense of grandiosity.
2. A decreased need for sleep such as feeling rested after only three hours of sleep.
3. More talkative than usual or a sense of pressure when talking.
4. Racing thoughts and flight of ideas.
5. Easily distracted.
6. Increase in goal-directed activity socially, at work or school, or sexually, or psychomotor agitation.
7. Excessive involvement in negative or high-risk situations such as engaging in unrestrained buying sprees, uninhibited sexual indiscretions, or foolish business investments.

C. The disturbance must be severe enough to cause significant impairment in social or occupational functioning, or to result in hospitalization to prevent harm to yourself or others, or if there are psychotic features present.

D. The episode cannot be attributed to the physiological effects of a substance such as a specific drug of abuse, a medication or other treatment or another medical condition.
Note: A full manic episode that emerged during antidepressant treatment or electroconvulsive therapy. Manic symptoms significantly at a level beyond the actual physiological effect of that treatment may be sufficient evidence for a manic episode and therefore of a bipolar one diagnosis.

Note: Criteria A-D above constitute a manic episode. At least one lifetime manic episode is required for the diagnosis of bipolar I disorder.

Coding for Specific Bipolar I Diagnoses:

The diagnostic code for bipolar I diagnosis are 296. _ _ (F31. _ _). The specific diagnosis and the related coding is based upon the current or most recent episode only. Mental health clinicians also need to consider and specify the severity, whether psychotic features are present, whether the client is in partial or full remission.

Some information adapted by Paul Susic Ph.D. Licensed Psychologist from the Diagnostic And Statistical Manual of Mental Disorders Fifth Edition DSM-5

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Are there effective psychosocial treatments for bipolar disorder?

Psychosocial treatments and psychotherapy for bipolar disorder: An overview

Psychosocial treatments are continuing to take a more prominent role in assisting in the mood stability of individuals with bipolar disorder. As an adjunct to pharmacotherapy (medication management of symptoms), family focused treatment strategies and cognitive behavioral therapy have been used to assist in successfully reducing relapse and intervening directly for bipolar depression and hypomanic episodes.

Psychosocial treatments for bipolar disorder are beginning to be recognized more often than in the past by experts as an adjunctive treatment to pharmacotherapy for the treatment and management of bipolar symptoms. Keck et al. (2004) recently found that experts are more consistently recommending psychotherapy and psychosocial interventions for the stages of bipolar disorder when patients are most receptive to interventions, such as when they are in an acute stage or in the maintenance phases of depressive and hypomanic episodes. However, these conclusions were not found when patients were experiencing acute manic or psychotic episodes. Psychological treatments and psychotherapy have also been recommended for the treatment of comorbid conditions such as when the patient has additional medical conditions such as eating or substance use disorders, or anxiety. It has been recommended as a first choice option when the use of medications is limited by comorbid medical conditions such as liver disease, renal conditions, obesity, pregnancy or heart disease.

Bipolar Disorder Psychosocial Treatments:

Some psychosocial treatments and psychotherapeutic interventions have demonstrated effectiveness for relapse prevention and in the earlier stages when the initial symptoms of bipolar disorder begin to occur. Cognitive behavioral therapy designed to treat existing symptoms and prevent relapse, individual cognitive behavioral therapy to treat bipolar depression, psychoeducational interventions and family-oriented interventions to assist in medication compliance and facilitating social support systems have demonstrated some effectiveness. Specific interpersonal related therapy along with interventions to assist with balancing sleep, awake, routine and activity cycles have been studied, although their effectiveness has not been proven at the present time.

The most effective psychosocial treatments seem to focus on some of the same basic principles: (1) Psychoeducation that helps patients to understand the role of medication compliance, and a basic understanding of their disorder as well as factors that aggravate the disorder such as issues related to sleep, regulating lifestyle and stress management; (2) communication and problem-solving training to reduce individual and family stress; (3) improving an understanding of early detection and intervention strategies such as increasing psychotherapy sessions, review of medications and increased family support and assistance. These interventions may be combined with additional cognitive behavioral strategies such as cognitive-restructuring, thought and activity monitoring, and other treatment interventions within an individual, family or group setting.

Cognitive Behavioral Therapy for Bipolar Disorder:

Typical cognitive behavioral therapy may include interventions for depression, balancing sleep and wake cycles and routine management, as well as monitoring of moods with a focus on the early detection of symptoms and initiating intervention. Lam and associates (2003) studied cognitive behavioral treatments and found some strong protective effects associated with the treatments, including a 43.8% relapse rate for individuals participating in cognitive behavioral therapy compared with a 75% rate for individuals from a control group who did not. Additional benefits were also identified in that the actual time spent in manic or depressive episodes was reduced significantly, and fewer days were spent hospitalized for the disorder.

Miklowitz et.al. (2003) found similar success with family interventions. In studies on family focused treatments that focus on psychoeducation for both bipolar patients and their families, along with assisting with communication and problem-solving have been found to be similarly effective. Interventions also included role-playing interventions and rehearsals both within and between sessions. Psychoeducational interventions included discussing risk and protective factors for mood episodes, along with rehearsal and relapse prevention efforts in the early stages of the bipolar episodes. The study by Miklowitz et al. (2003) found that in 21 sessions over a period of nine months of family focused treatments combined with medications, reduced both depression and manic symptoms as well as offered protection against relapse of bipolar episodes. These were compared to alternative interventions which focused on medication treatment along with two sessions of home-based family psychoeducation and crisis intervention over a period of nine months.

In another trial study by Rea et al. (2003), it was found that patients undergoing family focused therapy along with medication management had significantly longer delays in hospitalization and less relapse when compared to individuals undergoing only individual therapy consisting of medication compliance, psychoeducation, family support and problem-solving. Following the delivery of the active psychosocial treatments for a year, the rates of rehospitalization in the family focused therapy experience were only 12% as compared to 60% among the individuals receiving strictly individual therapy.

Summary of Psychosocial and Psychotherapeutic Interventions for Bipolar Disorder:

As reviewed in this article, several psychotherapeutic and psychosocial interventions have been found to be effective as an adjunct to the use of medications for the maintenance and early intervention to reduce the symptoms of bipolar disorder. The common principles involved in utilization of psychosocial treatments and psychotherapy for bipolar disorder focuses on the core belief that effective treatment needs to be a comprehensive, psychoeducational, cognitive behavioral, skill-based program, incorporating the family and social system which is oriented toward the long-term management of this chronic mental health condition.


Keck, D. A., Perlis, R.H., Otto, M.W., Carpenter, D., Docherty, J.P. & Ross, R. (2004). Expert Consensus Guideline Series: Treatment of bipolar disorder. A Postgraduate Medicine Special Report: December, 1-108.

Lam, D. H., Watkins, E. R., Hayward, P., Bright, J., Wright, K., Kerr, et all. (2003). A randomized controlled study of cognitive therapy for relapse prevention for bipolar affective disorder: Outcome of the first year. Archives of General Psychiatry, 60, 145-152.

Miklowitz, D. J., George, E. L., Richards, J. A., Simoneau, T. L., & Sudduth, R. L. et.al. (2003). A randomized study of family-focused psychoeducation and pharmacotherapy in the outpatient management of bipolar disorder. Archives of General Psychiatry, 60, 904-912.

Rea, M. M., Thompson, M. C., Miklowitz, D. J., Goldstein, M. J., Hwang, S., & Mintz, J. (2003). Family-focused treatment versus individual treatment for bipolar disorder: Results of a randomized clinical trial, Journal of Consulting and Clinical Psychology, 71, 482-492.

By Paul Susic Ph.D. Licensed Psychologist

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Bipolar Disorder Medication: Treatments of Choice?

Bipolar Disorder Medication Treatments: Overview

Bipolar disorder medication has been the treatment of choice for several decades now to control the severe and sometimes disabling symptoms of bipolar disorder. Doctors have been prescribing lithium and other mood stabilizers as well as anticonvulsant medications and atypical antipsychotics as the primary treatment for bipolar disorder along with the use of antidepressants and antianxiety medications, to help manage acute episodes as well as for the longer term management and to assist in managing future episodes.

Bipolar disorder medication treatments still rely upon the use of mood stabilizers such as lithium for the acute treatment of both manic and depressive episodes. Lithium has been used now for many decades to manage these moods and to prevent cycling into the other mood state. Doctors also have been known to use the anticonvulsants, antipsychotic medications, antidepressants, antianxiety and even sleep medications to manage the intense manic and depressive episodes as well as some of the associated problems, such as when the bipolar patient has a high level of anxiety or difficulty sleeping.

Mood stabilizers such as Lithium are used to prevent and treat the manic highs and the depressive lows. These medications are used to manage the symptoms so they do not interfere with school, work and with personal relationships. The main mood stabilizing medications are:

Divalproex sodium (Depakote)
Carbamazepine (Tegretol)
Lamotrigine (Lamictal)
Valproic acid (Depakene)

Some of these medications are also chategorized as anticonvulsants such as valproic acid, lamotrigine and carbamazepine.

Other medications used to treat bipolar disorder include the atypical antipsychotic medications. These include
Aripiprazole (Abilify)
Risperidone (Risperdal)
Quetiapine fumarate (Seroquel)
Olanzapine (Zyprexa)
Ziprasidone (Geodon)
Loxapine (Loxitand or loxapine inhaler (Adasuve)
Asenapine (Saphris)
Cariprazine (Vraylar)
Lurasidone (Latuda)

If an individual is experiencing insomnia or sleep difficulties in relation to their bipolar symptoms, they may receive prescriptions for antianxiety medications such as benzodiazepines. Some of the more common benzodiazepines include:

Alprazolam (Xanax)
Lorazepam (Ativan)
Diazepam (Valium)
Clonazepam (Klonopin)

Or frequently some of the newer sleep medication such as zaleplon (Sonata) and eszopiclone (Lunesta} will be prescribed as they are believed to cause fewer problems with thinking and memory then the antianxiety medicines, benzodiazepines.

Frequently, the doctor will prescribe the mood stabilizing medication lithium initially, but may also start a medication to also assist with the bipolar depression such as:

Fluoxetine (Prozac) which is combined with olanzapine (Zyprexa) to form a medication referred to as Symbyax
Quetiapine fumarate (Seroquel)
Lurasidone (Latuda) which may be taken either alone or with valproic acid or lithium.

Bipolar disorder medication treatments and depression:

Due to the predominance of depressive symptoms in bipolar disorder, antidepressants are often combined with mood stabilizers. However, there are significant concerns that the use of antidepressants can trigger manic episodes. These concerns have usually been related to the older antidepressants referred to as tricyclics rather than some of the newer serotonin reuptake inhibitors such as Paxil, Prozac and Zoloft. This risk was identified in a study by Gijsman, Geddes, Rendell, Nolen and Goodwin in 2004 in which it was found that there was a significant risk of the emergence of a manic conversion from depression among patients with a mood or anxiety disorder treated with tricyclic antidepressants, rather than when patients were treated with the SSRI’s. Also, even higher conversion rates from depression to manic episodes were found among younger antidepressant users.

Benzodiazepines and bipolar disorder:

Benzodiazepines have been used at times to reduce agitation and comorbid anxiety as an adjunctive medication treatment for bipolar disorder. However, the actual efficacy of these medicines has not been adequately studied at the present time when used in addition to the mood stabilizing medications.

Normal course of medication treatment for bipolar disorder:

Although mood stabilizers, antidepressants and other adjunctive medications have been used for the treatment of bipolar disorder for many years, the normal course of bipolar disorder continues to be one of relapse of episodes of mania/ hypomania and depression. Studies (Gitlin, Swenson, Heller, and Hammond, 1995) have found one-year relapse rates as high as 40% even while being treated with mood stabilizers. Medication compliance continues to be a major issue with patients with bipolar disorder, with one study (Keck et al., 1998) finding inadequate medication use among approximately one half to two thirds of the patients within one year of initial treatment. Discontinuing the use of medications and the related relapse of bipolar symptoms with these patients is very problematic, especially when these medications have been stopped abruptly. Psychological treatments have been successfully utilized to promote medication compliance and to improve the symptom course of bipolar disorder patients. Overall, psychosocial interventions and psychotherapy have been found to improve the management of long-term bipolar symptoms and assist in relapse prevention.


Gijsman, H.M., Geddes, J.R., Rendell, J.M., Nolen W.A. and Goodwin, G.M. (2004). Antidepressants for bipolar depression: a systematic review of randomized, controlled trials. American Journal of Psychiatry, 161, 1537-1547.

Gitlin, M.J., Swenson, J., Heller, T.L. and Hammen, C. (1995). Relapse and impairment in bipolar disorder. American Journal of Psychiatry, 152, 1635-1640.

Keck, P.E., McElroy, S.L., Strakowski, S.M., West, S.A., Sax, K.W., Hawkins et al (1998). Twelve-month outcome of patients with bipolar disorder following hospitalization for a manic or mixed episode. American Journal of Psychiatry, 155, 646-652.

By Paul Susic Ph.D. Licensed Psychologist

Bipolar Disorder: What is it exactly?

Bipolar Disorder an Overview:

Dipolar disorder, formerly called manic depression is a chronic and very disabling condition. Bipolar disorder is a disorder of instability in mood, behaviors and lifestyle. The main feature of bipolar disorder is a manic episode followed by either another episode of mania at a later point in time, depression or hypomania. In most cases, one or more of these patterns occur repeatedly and chronically over an individual’s lifetime. The overall diagnosis of bipolar disorder is usually bipolar I or bipolar II disorder, with a reference to the most recent episode of “manic, hypomanic or depressed”. Specific symptoms and diagnosis can be found on this website by referring to the bipolar disorder diagnostic pages.

Individuals diagnosed with bipolar disorder may have very different symptom patterns. Some episodic symptom patterns seem to have some balance between episodes of mania, depression and hypomania, while others seem to have predominately one symptom pattern. Some researchers have found that among individuals with bipolar I disorder depressive episodes seem to predominate, with over 3.5 times as many weeks of depression relative to weeks experiencing manic episodes or hypomania. Most bipolar individuals will receive a diagnosis of bipolar disorder I most- recent episode depressed at some point in their mental health history. Individuals with bipolar II disorder, have 38 times more depressive symptoms than hypomanic symptoms.

People diagnosed with bipolar disorder experience tremendous levels of functional impairment in their lives even while maintained on medication. These deficits in functioning are very comprehensive including work-related, academic and interpersonal functioning. Some studies have found that even while maintained on medicine that deficits in functioning continue for as much is five years after the depressive or manic episodes have remitted. Some researchers (Dion, Tohen, and Anthony, 1998) have concluded that 30% of these individuals were unable to work at all and only 21% were able to work at their previous level of functioning following a manic, depressive or hypomanic episode. Similar findings were also found for individuals already on medication for bipolar disorder. Only a small percentage of manic patients seem able to work consistently following hospitalization. Bipolar disorder is also found to be associated with very high levels of marital and family distress, dysfunction and divorce.

Bipolar Disorder: Some Basic Information

Bipolar disorder has been estimated to affect about 1% to 2% of the general population. These estimates may be even higher levels when considering the entire bipolar spectrum including cyclothymia.
The initial onset of bipolar disorder seems to be in the late teens to early twenties. People with early onset disorder seem to have a higher level of additional comorbid symptoms, including conditions such as substance abuse and anxiety disorders. Also, early onset patients seem to have a more chronic course, with more episodes of depression and to have a higher likelihood of suicidal behaviors.

Men and women both seem to have about the same likelihood of developing bipolar disorder. However, more women than men seem to have the rapid cycling pattern, which is defined as four or more cycles in a year, as well as being diagnosed with bipolar II disorder more often.

People with bipolar disorder seem to experience comorbidity with several other mental health conditions and disorders. The most common comorbid conditions experienced by individuals with bipolar disorder include panic disorder, social anxiety disorder, posttraumatic stress disorder, obsessive-compulsive disorder and generalized anxiety disorder. High rates of substance use disorders have been identified in clinical populations as well, with some clinicians believing that the rates may be as high as six times the general population.

The General Course of Bipolar Disorder:

The general course of bipolar disorder is to have repeated manic, depressive and hypomanic episodes that significantly impair an individual’s work and school experiences as well as their personal relationships. Also, these disruptions in functioning may increase the intensity and frequency of the symptoms and episodes. Over the long-term, about three fourths of the individuals who have met the diagnostic criteria for bipolar disorder will have a relapse within a period of 4 to 5 years, with about half having a relapse the following year. As previously mentioned, the residual impairment in functioning seems to continue even in between symptom episodes.

A number of factors seem to be associated with the increased frequency or likelihood of a mood episode. Stressful life and family experiences seem to delay recovery and increase the rate of relapse. It is believed that stressful family experiences and negative interaction patterns are associated with greater relapse rates.

The high level of comorbidity is also associated with a more difficult course. There appears to be significant evidence to support the fact that anxiety and substance use disorders are particularly significant to the appearance, maintenance and relapse of bipolar symptoms and episodes. Clinical experience also seems to confirm that the comorbid existence of anxiety in addition to bipolar disorder is linked to a reduced likelihood of recovery from a mood episode, reduced ability to function in everyday life, greater likelihood of suicide attempts and a reduced ability to respond to some medications. Comorbid substance abuse disorders often cause an individual to experience poor recovery, increase the level of noncompliance with an individual’s medication routine, and increase the frequency of hospitalization. Some individuals may also experience psychotic episodes during depressive episodes resulting in significantly impaired functioning and relapse.

Suicide is also a great concern among individuals with bipolar disorder. Researchers (Brown, Beck, Steer, and Grisham, 2000) have evaluated the course of over 7000 psychiatric outpatients in Pennsylvania diagnosed according to the DSM-IV criteria and found that among the various mental health diagnosis, bipolar disorder patients have the highest level of completed suicides, followed by major depressive disorder and personality disorders. When compared to what are determined to be relatively average psychiatric patients, patients with bipolar disorder seem to have about a 400% higher risk of suicide followed by major depressive disorder which seems to have about 300% higher risk for suicide.

Bipolar Disorder Treatments:

Optimum treatment for bipolar related disorders includes psychotherapy and mood stabilizing medications. Some the primary psychological treatments include psychoeducation, cognitive behavior therapy, family-focused therapy, and interpersonal social rhythm therapy. Lithium and other mood stabilizing medications have had a high rate of success in stabilizing bipolar symptoms and episodes. Individuals who are noncompliant with their medications continue to have very high rates of relapse however.


Brown, G.K., Beck, A.T., Steer, R.A. & Grisham, J.R. (2000) Risk factors for suicide in psychiatric outpatients: A 20-year prospective study. Journal of Consulting and Clinical Psychology, 68, 371-377.
Dion, G.L.,Tohen, M., and Anthony, W.A., (1998). Symptoms and functioning of patients with bipolar disorder six months after hospitalization. Hospital Community Psychiatry, 39, 652-657.

By Paul Susic Ph.D. Licensed Psychologist

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Bipolar I Disorder: Current or Most Recent Episode Depressed Diagnosis

Bipolar I Disorder: Current or Most Recent Episode Depressed Diagnosis – General Information

In order to have a Bipolar I Disorder: Current or Most Recent Episode Depressed diagnosis you must have at least one manic episode previous to the current or most recent episode of depression. Nearly every person with bipolar I disorder will have or can have the diagnosis of “current or most recent episode depressed” at some point in time in their mental health history.

A diagnosis of Bipolar I Disorder: Current or Most Recent Episode Depressed obviously requires a depressive episode which includes (as previously mentioned) a manic episode followed by a depressive episode. The depressive episode requires either a depressed mood for at least two weeks or a loss of interest or pleasure in normally pleasurable activities, and at least five of the depression symptoms listed in 1-9 below.

Bipolar I Disorder: Important Information

Bipolar I Disorder: Current or Most Recent Episode Depressed and bipolar I disorder in general, is a very serious mental health condition. Bipolar I disorder has a lifetime prevalence of 0.8%. Obviously, a significant percentage of people suffer from these severe mood episodes. In actuality, contrary to popular belief, bipolar I disorder is not always indicated by rapid mood swings, with some mood episodes going on for weeks or months at a time. They may resolve and then resume with a later mood episode.

Bipolar I disorder in addition to major depressive disorder can be lethal. Some researchers have found that between 25% and 50% of individuals suffering from this disorder may attempt suicide. In addition, individuals experiencing a manic episode may engage in very risky behaviors resulting in severe consequences. The healthcare costs associated with bipolar I disorder are very high because of the frequency of hospitalizations, doctor visits and the usage of expensive medications.


Bipolar I disorders occur just as frequently among women as in men, although women tend to experience more rapid cycling and more frequent depressive episodes than men. Also, in addition to the bipolar I symptoms, women seem to experience higher rates of comorbid eating disorders and substance use disorders. Unfortunately, individuals who are diagnosed with bipolar I disorders often have a lower socioeconomic status, have much higher rates of disability and a lowered life expectancy.

Bipolar I Disorder: Current or Most Recent Episode Depressed Treatments

Bipolar I Disorder: Current or Most Recent Episode Depressed is most often treated with mood stabilizing medications and antidepressants, along with psychological interventions. These disorders require lifelong management. Many researchers and clinicians agree that the combination of psychotherapy and medications is the most effective treatment for this disorder.

The most effective interventions according to research literature seem to include medications combined with psychoeducation, cognitive behavioral therapy, family-focused therapy, and other types of interpersonal and social rhythm therapy.

The specific symptoms associated with Bipolar I Disorder: Current or Most Recent Episode Depressed follow below.

Basic Bipolar I Disorder Diagnosis Criteria

A. Criteria have been met for at least one manic episode.
B. The occurrence of the manic and major depressive episode or episodes is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other schizophrenia spectrum and other psychotic disorders.

Major Depressive Episode:

A. At least five of the following symptoms have been present during the same two week period and represent a significant change from previous functioning; At least one of the symptoms must be either (1) depressed mood or (2) loss of interest or pleasure in normal activities.
Note: Never include symptoms that are clearly attributable to another medical condition.

1. Depressed mood most of the day, nearly every day, as indicated by either an individual’s subjective report, such as feelings of sadness, emptiness or hopelessness, or observation by others such as that they appear tearful or sad. (Note: In children and adolescents it can be an irritable mood.)
2. A significantly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day as indicated by either an individual’s subjective account or observation by others.
3. A significant weight loss when not dieting or a weight gain such as a change of more than 5% of body weight in a month, or a decrease or an increase in appetite nearly every day. (Note: in children, consider a significant failure to make expected weight gain.)
4. Insomnia or hypersomnia nearly every day.
5. Psychomotor retardation or agitation nearly every day which may be observable by others and cannot be merely subjective feelings of restlessness or being slowed down.
6. Fatigue or loss of energy nearly every day.
7. Feelings of worthlessness or inappropriate or excessive guilt (which may be delusional) nearly every day.
8. Diminished ability to concentrate, to think or be decisive, nearly every day, either by subjective account or be observable by others.
9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a plan or suicide attempt or a specific plan for committing suicide.

B. The symptoms above cause significant distress or impairment in an individual’s social, occupational, educational or other important areas of functioning.

C. The episode above is not attributable to the physiological effects of a medication, substance, or to another medical condition.

Note: Criteria A-C, see above to indicate a major depressive episode. Major depressive episodes are common in individuals with Bipolar I disorder but are not absolutely required for the diagnosis of the disorder.

Note: Responses to a significant loss such as bereavement, financial ruin, losses from a natural disaster, serious medical illness or disability may include the feelings of intense sadness, ruminating about the loss, insomnia, poor appetite, and weight loss noted in criterion A above, which may resemble a depressive episode. Although such symptoms may be understandable or even appropriate to the loss, the presence of a major depressive episode in addition to the normal response to a significant loss should also be considered very carefully. This decision obviously requires the exercise of clinical judgment based upon the individual’s history and cultural norms for the expression of the distress in the context of the loss.

Coding for Bipolar I Disorder: Current or Most Recent Episode Depressed and other bipolar one disorders:

The diagnostic code for bipolar I disorder is 296._ _ (F31._ _). The actual specific coding defines either the current or most recent episode only. Also, psychologists, psychiatrists and other mental health clinicians need to specify the severity, whether psychotic features are present and finally if the patient is in partial or full remission.

Some information adapted by Paul Susic Ph.D. Licensed Psychologist from the Diagnostic And Statistical Manual of Mental Disorders Fifth Edition DSM-5

Bipolar and Related Disorders and DSM-5 Diagnostic Codes

Bipolar and Related disorders:

The bipolar in bipolar disorder refers to the fluctuation between depression and mania sometimes in a very dramatic, severe way. Earlier in the 19th century, mental health professionals used the terms manic depression and affective psychosis to describe bipolar disorder. In the first edition of the DSM (Diagnostic And Statistical Manual of Mental Disorders), bipolar disorder was referred to as manic depressive illness and was later renamed bipolar disorder in the DSM-III because of the stigma attached to mania and an attempt to describe and focus on the polarity between the two different symptom patterns of depression and mania.

The diagnosis of bipolar disorder has increased significantly especially among adolescents since the DSM-III. A report by CNN concluded that as many as 4.4% of individuals in the United States may receive some type of diagnosis along the bipolar spectrum in their lifetime. Unfortunately, individuals with bipolar disorder have the highest suicide rate among all of the mental health disorder diagnoses, with the rate of anywhere from 10 to 20 times higher than the general population in the United States.


Specific Bipolar and Related Disorders and DSM-5 Diagnostic Codes:

The following specifiers apply to bipolar related disorders were indicated: specify: with anxious distress (specify current severity: mild, moderate, moderate-severe, severe); with mixed features; with rapid cycling; with melancholic features; with atypical features; with mood-incongruent psychotic features; with mood-incongruent psychotic features; with catatonia (use additional code 293.89 [F06. 1]); with peripartum onset; with seasonal pattern

Bipolar I Disorder:

Current or Most Recent Episode Manic:
296.41 (F31.11) Mild
296.42 (F31.12) Moderate
296.43 (F31.13) Severe
296.44 (F31.2) With psychotic features
296.45 (31.73) In partial remission
296.46 (F31.74) In full remission
296.40 (F31.9) Unspecified
296.40 (F31.0) Current or most recent episode hypomanic
296.45 (F31.73) In partial remission
296.46 (F31.74) In full remission
296.40 (F31.9) Unspecified

Current or Most Recent Episode Depressed:
296.51 (F31.31) Mild
296.52 (F31.32) Moderate
296.53 (F31.4) Severe
296.54 (F31.5) With psychotic features
296.55 (F31.75) In partial remission
296.56 (F31.76) In full remission
296.50 (F31.9) Unspecified

296.7 (F31.9) Current or most recent episode unspecified

296.89 (F31.81) Bipolar II Disorder

Specify current or most recent episode: Hypomanic, Depressed

Specify courses if full criteria for a mood episode are not currently met: In partial remission, In full remission
Specify severity if full criteria for a mood episode are not currently met: Mild, Moderate, Severe

301.13 (F34.0) Cyclothymic Disorder

Specify if: With anxious distress
Substance/Medication – Induced Bipolar and Related Disorder
Note: See the criteria set a corresponding recording procedures for substance-specific codes and ICD-nine-CM and ICD-10-CM coding.

293. 83 Bipolar Related Disorder Due to Another Medical Condition
specify if:
(F06.33) With manic features
(F06. 33) With manic-or hypomanic-like episode
(F06. 34) With mixed features

296.89 (F31.89) Other Specified Bipolar Related Disorder

296.80 (F31.9) Unspecified Bipolar and Related Disorder

New study says simple EEG can identify major depression or bipolar disorder.

EEG can identify major depression or bipolar disorder

A new study at Loyola University has concluded that a simple electrocardiogram that takes all of 15 minutes may help a doctor decide whether a patient has major depressive disorder or bipolar disorder. Because of the frequent misdiagnosis of both bipolar disorder and major depression, the study is believed to help distinguish between the two. Because the symptoms of major depression and the depressive phase of bipolar disorder are similar it is frequently hard to distinguish between the two. However, the treatments are very different.

When an individual has bipolar disorder they have experienced at some point in time at least one manic episode, which is an emotional high. Mania is not a normal characteristic of major depressive disorder and so, the treatments are significantly different. With bipolar disorder, when in the depressive phase an individual may be given an antidepressant along with a medication to stabilize the mood or sometimes an antipsychotic medication to prevent the patient from switching to a manic phase. A doctor misdiagnosing the bipolar disorder may attempt to treat the depression without treating the mania and prescribe an antidepressant without the mood stabilizing medication.

Heart Rate Variability: Depression and Bipolar Disorder

The Loyola study found that heart rate variability measured by an EEG or an electrocardiogram was able to identify whether individuals had bipolar disorder or major depression. The measure of heart rate variability is able to identify if there is a variation in the time interval between heartbeats.

Published in the World Journal of Biological Psychiatry senior author Angelos Halaras M.D., Ph.D. and professor in Loyola’s Department of Psychiatry and Behavioral and Neural Sciences and medical director of the adult psychiatry unit stated that “having a noninvasive, easy-to-use and affordable test to differentiate between major depression and bipolar disorder would be a major breakthrough in both psychiatric and primary care practices.”

Major depression is by far one of the most common mental health disorders with some estimates as high as 8% to 10% of the population having it at any one period in time. While bipolar disorder may be a little less prevalent, estimates are as high as 50 million people suffering from bipolar disorder worldwide. Both can be very severe and debilitating.

All of the subjects in the research study underwent electrocardiograms at the initiation of the study, rested comfortably for 15 minutes while a EEG was attached to their chest. EEG data was then collected for the next 15 minutes and the data was then converted by a special software package developed by the study’s co-author Stephen W Porges, Ph.D. of Indiana University’s Kinsey Institute.

Researchers then computed what is known to cardiologists as respiratory sinus arrhythmia (RSA) while measuring the heart rate variability. Researchers found that at the beginning of the study a baseline was set in which individuals with major depression had much higher RSA than subjects with bipolar disorder.

Researchers also found that subjects with bipolar disorder also had higher blood levels of inflammation that individuals with major depressive disorder. Inflammation is believed to be increased when the immune system experiences heightened stress as may be experienced by an individual with bipolar disorder.

Article adapted by Paul Susic Ph.D. Licensed Psychologist from ScienceDaily Dated November 21, 2017: Simple electrocardiogram can determine whether a patient has major depression or bipolar disorder, study finds

Journal Reference:

Brandon Hage, Briana Britton, David Daniels, Keri Heilman, Stephen W. Porges, Angelos Halaris. Low cardiac vagal tone index by heart rate variability differentiates bipolar from major depression. The World Journal of Biological Psychiatry, 2017; 1 DOI: 10.1080/15622975.2017.1376113

Bipolar disorder: Is it as bad as they say it is?

Bipolar Disorder:Overview

Bipolar disorder is a chronic, frequently disabling condition, previously referred to as manic depression. Bipolar disorder is characterized by mood instability that includes at least one episode of mania or hypomania in conjunction with repeated episodes of major depression. Mania is characterized by at least one week of a high feeling, euphoria and irritability along with four or more the following symptoms: racing thoughts, reckless behavior, very limited need for sleep, distractibility and pressured speech (American Psychiatric Association, 2012). Hypomania is usually characterized by symptoms that are very similar but somewhat less severe than mania. There are several subtypes of Bipolar disorder including Bipolar I and Bipolar II disorder. The Bipolar I subtype is defined by at least one episode of mania or mixed disorder, while the Bipolar II subtype is seen in individuals who never seem to have a complete or full manic episode while having at least one hypomanic episode along with one or more episodes of depression.

Individuals with bipolar disorder often exhibit very different symptom patterns from each other. Some individuals may have only one manic episode along with a long history of major depressive episodes. Others may have some balance of episodes of depression and hypomania or mania. In most cases however, individuals experience more depressive episodes than manic or hypomanic episodes. Some studies have found that individuals with Bipolar I disorder seem to have about 3.5 times as many weeks with symptoms of depression rather than weeks of manic or hypomanic episodes. Bipolar II patients seem to have 38 times more weeks of depression relative to weeks exhibiting hypomanic symptoms.

Functional impairment:

Individuals with Bipolar disorder often have significant impairment as a result of their symptoms and are frequently disabled. The symptoms often impair functioning to the degree that they may have great difficulty in their daily experiences of work, relationships and in general conformity with social expectations. Some studies have found that functional deficits associated with manic episodes such as difficulties in relationships and work continue to be obvious five years after the episode was resolved. Other studies have found that approximately 30% of patients were unable to work and only 21% work at what may be considered their expected level work effectiveness in the six months subsequent to an episode of mania. While medications seem to be very helpful, only 35% of patients utilizing medicine seem to have good function 4 and 1/2 years after the manic episode. Additional studies have found that only about 42% of manic patients were able to work steadily in the 1.7 years after they were hospitalized for a manic episode. Also, very high rates of marital distress, dysfunction and divorce are associated with Bipolar disorder.


There is really no gender difference in the presentation of Bipolar disorder as women and men seem to receive this diagnosis at about the same rate. There have been some differences noted however for individuals referred to as rapid cycling (which is when people seem to have four or more episodes in one year), with more women being defined as having the rapid cycling subtype of Bipolar II disorder

Age of Onset:

Bipolar disorder seems to present most often in the late teens to the early twenties. Individuals with earlier onset seem to have a more chronic presentation along with more severe substance abuse and anxiety along with a higher likelihood of suicidal behaviors.


This disorder is believed to effect approximately 1% and 2% of the population in the United States. However, some studies have found higher rates when considering the entire bipolar spectrum which also includes cyclothymia.

Clinical Course:

Bipolar disorder is most commonly experienced as repeated cycles or episodes of depression and mania or hypomania that are extremely dysfunctional and often disabling. These mood disruptions are also accompanied by family and work difficulties as well as severe problems at work and in social situations. Over a period of 4 to 5 years, most bipolar patients relapse into additional episodes with the most frequent relapse being within the first year of diagnosis. The frequency and related impairment is largely responsible for the role disruption associated with this disorder.

There are many factors associated with the likelihood of a mood episode. One of the more common exacerbating factors seems to be stressful life experiences. Stress has been found to increase the likelihood of a episodes as well as often increasing the level of intensity. Comorbid factors include an increased rate of alcohol or substance abuse and/or high levels of anxiety. These comorbid factors are also known to indicate a poorer rate of recovery as well as increasing the impairment in role functioning as well as a possibly causing a higher frequency of suicide attempts. Bipolar disorder patients are also frequently noncompliant with their medications reducing or impairing their recovery often resulting in more frequent hospitalization. Unfortunately, some individuals with this disorder may experience some level of psychosis especially during the depressive episode, which also lessens the possibility of a full recovery.

Suicide is of great concern among bipolar patients. Some researchers have found that when compared to other psychiatric patients, patients receiving a DSM IV or DSM V diagnosis for bipolar disorder seem to have the highest rate of completed suicide, followed by individuals with major depressive disorder and personality disorders.

Conclusions on bipolar disorder:

Bipolar disorder is easily one of the most severe and disabling of the psychiatric diagnoses. It effects virtually every aspect of personal, family, social and occupational functioning. Individuals suspected of having bipolar disorder absolutely need to have the assessment of a qualified mental health practitioner such as a psychologist, psychiatrist or mental health counselor. They need to have social support to reduce stress and assist in everyday activities as well as maintaining compliance with their medications from family and friends. Medications continue to improve and assist in moderating and stabilizing moods. Also, the assistance of psychotherapy and counseling seems to have some effectiveness in reducing stress, assisting with problem-solving life difficulties, maintaining compliance with medications as well as advocating for the best interest of the individual with bipolar disorder.

By Paul Susic Ph.D. Licensed Psychologist

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