Geriatric Bipolar Disorder - General Principles of Treatment - UpToDate

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Geriatric bipolar disorder: General principles of

treatment
AUTHORS: Martha Sajatovic, MD, Peijun Chen, MD, MPH, PhD
SECTION EDITORS: Paul Keck, MD, Kenneth E Schmader, MD
DEPUTY EDITOR: David Solomon, MD
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Jan 2024.

This topic last updated: Sep 27, 2023.
INTRODUCTION
The treatment of older bipolar patients differs from the treatment of younger patients [1].
Up to 25 percent of all bipolar patients are older adults [2], and the absolute number of
geriatric bipolar patients is expected to increase as the world’s population ages over the next
several decades [3,4].
This topic reviews the general principles of treating geriatric bipolar disorder. The
epidemiology, pathogenesis, clinical features, assessment, diagnosis, acute treatment and
prognosis, and maintenance treatment of geriatric bipolar disorder are discussed separately,
as are the epidemiology, clinical features, diagnosis, acute treatment, and maintenance
treatment of bipolar disorder in mixed-age patients.
● (See "Geriatric bipolar disorder: Epidemiology, clinical features, assessment, and

diagnosis".)
● (See "Geriatric bipolar disorder: Treatment of mania and major depression".)
● (See "Geriatric bipolar disorder: Maintenance treatment".)
● (See "Bipolar disorder in adults: Epidemiology and pathogenesis".)
● (See "Bipolar disorder in adults: Clinical features".)
● (See "Bipolar disorder in adults: Assessment and diagnosis".)
● (See "Bipolar mania and hypomania in adults: Choosing pharmacotherapy".)
● (See "Bipolar major depression in adults: Choosing treatment".)
● (See "Bipolar disorder in adults: Choosing maintenance treatment".)
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DEFINITION OF GERIATRIC BIPOLAR DISORDER
The minimum age used to define geriatric bipolar disorder is generally 60 years [5,6].
However, some authorities use an age cut-off of 50, 55, or 65 years [7]. The International
Society for Bipolar Disorders Task Force on Older-Age Bipolar Disorder recommends that
older age bipolar disorder include patients ≥50 years [6].
Geriatric bipolar disorder includes both aging patients whose mood disorder presented
earlier in life and patients whose mood disorder presents for the first time in later life [1,8].
The International Society for Bipolar Disorders Task Force uses the term “older age bipolar
disorder” instead of “geriatric bipolar disorder” [6].
Bipolar disorder in both geriatric and younger patients is characterized by episodes of major
depression ( table 1), mania ( table 2), and hypomania ( table 3) [9]. The clinical
features and diagnosis of geriatric bipolar disorder are discussed separately. (See "Geriatric
bipolar disorder: Epidemiology, clinical features, assessment, and diagnosis".)
GENERAL PRINCIPLES
Goal of treatment — The goal of acute treatment for late-life bipolar mood episodes is
remission, which is defined as resolution of the mood symptoms or improvement to the
point that only one or two symptoms of mild intensity persist. If psychotic features (eg,
delusions or hallucinations) are also present, resolution of these features is required for
remission. For patients who do not achieve remission, a reasonable goal is response, which
is defined as stabilization of the patient’s safety and substantial improvement in the number,
intensity, and frequency of psychotic and mood symptoms; response is often operationalized
as a reduction of baseline symptoms ≥50 percent, using standardized assessment scales.
(See 'Monitoring' below.)
After acute treatment, the goals are functional recovery and prevention of recurrent mood
episodes. Functional recovery includes restoring occupational performance, social
relationships, daily routines, and meaningful life interests [10].
Initial evaluation — Treatment for geriatric bipolar patients begins with a psychiatric and
general medical history, mental status and physical examination, and focused laboratory and
imaging studies. The evaluation establishes the diagnosis of bipolar disorder, the comorbid
disorders that require treatment, contraindications to treatment (eg, renal impairment and
use of lithium, or hepatic disease and use of valproate), as well as biopsychosocial factors
that may affect treatment and recovery. The assessment for late-life bipolar disorder is
discussed separately. (See "Geriatric bipolar disorder: Epidemiology, clinical features,
assessment, and diagnosis", section on 'Assessment'.)
Level of care — The treatment setting for geriatric bipolar disorder depends upon the type
and severity of symptoms, presence of comorbid psychopathology (eg, substance use
disorder), level of psychosocial functioning, and available support. Hospitalization may be
required for safety and stabilization, particularly for severely ill patients with:
● Suicidal ideation with a specific plan and intent

● Delusions or hallucinations that place the patient at imminent risk of coming to harm
● Catatonia, mixed features, or rapid cycling
● Significant behavioral disturbances (eg, aggression or wandering)
● Substance use that is exacerbating the mood episode
● Impaired functioning (eg, inability to feed or clothe oneself) and lack of support
Moderately ill patients with late-life bipolar disorder can generally be treated in a partial
hospital (day) program or residential facility (eg, nursing home), including patients with
suicidality that does not pose an imminent risk (eg, fleeting thoughts of killing oneself with
vague or nonexistent plans and no intent). An outpatient clinic may be suitable for less
acutely ill patients (eg, thoughts that family members would be better off if the patient was
dead, with no plan or intent to commit suicide).
Pharmacologic issues — Clinicians should “start low and go slow” when prescribing
medications for geriatric bipolar patients, especially frail, medically compromised patients
who have difficulty tolerating medications [11-15]. Comorbid diseases, concomitant
medications, and age-related physiologic changes can alter a drug’s pharmacodynamics and
pharmacokinetics, which often affect therapeutic and adverse responses. Thus, we suggest
that clinicians:
● Start the drug at a low dose

● Increase the dose by small increments every one to seven days
● Exercise caution regarding side effects
● Coordinate care with other clinicians who are managing general medical comorbidity
Older bipolar patients taking multiple medications due to comorbid illnesses are at risk for
drug-drug interactions. As an example, serum concentrations of lithium may be increased by
concomitant use of angiotensin converting enzyme inhibitors, calcium antagonists,
cyclooxygenase 2 inhibitors, loop diuretics, nonsteroidal anti-inflammatory drugs, and
thiazide diuretics [16], and adjustment of lithium doses to target an age-appropriate
therapeutic serum level is warranted [17]. Specific interactions of any drug with other
medications may be determined by using the drug interactions program included in
UpToDate.
A review of 34 treatment guidelines from 19 countries found that recommendations for

choosing medications for geriatric bipolar disorder are generally similar to
recommendations for younger adults, with the caveat that general medical comorbidity and
concomitant medications can render older adults more vulnerable to adverse effects [18].
The relative lack of recommendations that are specific to older patients is due in part to the
lack of randomized trials in this population. Other than trials such as GERI-BD, which
compared lithium with divalproex for acute, late-life mania [19], evidence for the efficacy of
medications largely comes from subgroup analyses of results for geriatric patients enrolled
in randomized trials conducted with mixed-age adult bipolar patients (18 to 65 years). These
studies generally show that response is comparable for older and younger patients [20,21].
However, target serum concentrations (eg, lithium) may be lower for older patients than
younger patients [22].
Geriatric bipolar mania and bipolar major depression are commonly treated with a
combination of psychotropic medications [23-25]. In addition, mood episodes with psychotic
symptoms generally require a second-generation antipsychotic such as quetiapine or
olanzapine, either as monotherapy or combined with lithium or valproate [26-28]. More
detailed information about choosing medications for patients with geriatric bipolar disorder
is discussed separately. (See "Geriatric bipolar disorder: Treatment of mania and major
depression" and "Geriatric bipolar disorder: Maintenance treatment".)
Monitoring — Compared with younger patients, geriatric bipolar patients suffer more
general medical comorbidity and medication side effects, and thus often require more
vigilant treatment monitoring [29]. Hospitalized geriatric patients are monitored daily.
Outpatients are commonly seen on a weekly basis until they have responded (eg, the
number, intensity, and frequency of mood symptoms has improved by at least 50 percent)
and have tolerated the medication regimen for two to four weeks. At that point the patient
can be seen every two to four weeks until they remit. Following remission, patients receive
maintenance treatment and the schedule for monitoring is decreased. (See "Geriatric bipolar
disorder: Maintenance treatment", section on 'Monitoring the patient'.)
The patient’s psychiatric status can be quantified with standardized rating scales such as the
clinician administered Brief Psychiatric Rating Scale (assesses psychosis) [30], clinician
administered Young Mania Rating Scale (assesses mania) [31], and the self-report Patient
Health Questionnaire – Nine Item (assesses depression) ( table 4) [32], but this is not
standard clinical practice.
Adjunctive psychoeducation — Patients with geriatric bipolar disorder may possibly benefit
from adding group psychoeducation to pharmacotherapy:
● A two-year randomized trial compared a group psychoeducation program plus usual

care with usual care alone in 183 patients with serious mental illness (including 20
percent with bipolar disorder) [33]. The group program met weekly during year 1 and
monthly during year 2, and focused upon social rehabilitation and social skills training;
usual care included pharmacotherapy and case management. Follow-up assessments

one year posttreatment found that improvement of psychiatric symptoms and
psychosocial functioning was greater in patients who received adjunctive
psychoeducation.
● A prospective observational study evaluated a 12-week, adjunctive group

psychoeducation program focused upon medication adherence in 21 older bipolar
patients, most of whom were depressed [34]. Clinically small to moderate improvement
in depressive symptoms occurred in the 16 patients who completed the study.
General medical comorbidity — Geriatric bipolar mood episodes, which are comorbid with
or secondary to general medical conditions, are managed with concurrent treatment of the
medical condition and mood symptoms. Mood episodes associated with general medical
conditions are discussed separately. (See "Geriatric bipolar disorder: Epidemiology, clinical
features, assessment, and diagnosis", section on 'General medical conditions'.)
Managing nonresponse — If patients with geriatric bipolar disorder do not respond to

initial treatment, we suggest the following steps:
● Verify that the patient has bipolar disorder rather than a different condition such as
secondary mania. (See "Geriatric bipolar disorder: Epidemiology, clinical features,
assessment, and diagnosis", section on 'Differential diagnosis' and "Bipolar disorder in
adults: Assessment and diagnosis", section on 'Differential diagnosis'.)
● Ask about adherence with treatment because nonadherence is common during

treatment of psychiatric disorders; improving adherence with pharmacotherapy or
psychotherapy homework can convert nonresponders to responders. (See "Bipolar
disorder in adults: Managing poor adherence to maintenance pharmacotherapy".)
● Determine whether there are significant life stressors (eg, social isolation) that need to
be addressed.
● Establish if comorbid psychopathology (eg, anxiety disorder, substance use disorder, or

dementia) is present and treated (see "Geriatric bipolar disorder: Epidemiology, clinical
features, assessment, and diagnosis", section on 'Psychiatric disorders'). If a disorder
other than bipolar disorder is more salient, treatment should refocus upon the primary
problem.
Making referrals — Primary care clinicians often treat geriatric patients with bipolar
disorder. However, the diagnosis may not be clear or these clinicians may not be comfortable
managing the disorder and thus refer patients to psychiatrists; referrals are also made if
requested by patients. In addition, referral is usually indicated for patients with:
● Severe mood episodes
● Numerous recurrent episodes (eg, three or more in the span of three years)
● Suicidal ideation or behavior (see "Suicidal ideation and behavior in adults")
● Aggressive behavior (see "Bipolar mania and hypomania in adults: Choosing

pharmacotherapy", section on 'Agitation' and "Assessment and emergency
management of the acutely agitated or violent adult")
● Psychotic features (eg, delusions or hallucinations) (see "Bipolar disorder in adults:

Clinical features", section on 'Psychosis')
● Catatonia (see "Catatonia in adults: Epidemiology, clinical features, assessment, and

diagnosis")
● Mixed features (see "Bipolar disorder in adults: Clinical features", section on 'Mixed
features')
● Poor judgment that places the patient or others at imminent risk of harm
● Psychiatric comorbidity, such as anxiety disorders or substance use disorders (see

"Geriatric bipolar disorder: Epidemiology, clinical features, assessment, and diagnosis",
section on 'Psychiatric disorders')
● Nonresponse to pharmacotherapy and psychotherapy
● Bipolar major depression ( table 1)
In addition, referral to social work may be appropriate; indications include problematic social
circumstances, such as intimate partner violence or other trauma, social isolation, poverty, or
homelessness. Social workers may also facilitate treatment uptake and/or additional
supports that may be needed to help manage aging-related issues such as reduced ability to
drive/travel or need for assistance with meals.
CHOOSING SPECIFIC TREATMENTS
Choosing specific treatments for geriatric bipolar disorder is discussed separately. (See
"Geriatric bipolar disorder: Treatment of mania and major depression" and "Geriatric bipolar
disorder: Maintenance treatment".)
SOCIETY GUIDELINE LINKS
Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: Bipolar disorder".)
INFORMATION FOR PATIENTS
UpToDate offers two types of patient education materials, “The Basics” and “Beyond the
Basics.” The Basics patient education pieces are written in plain language, at the 5th to 6th
grade reading level, and they answer the four or five key questions a patient might have
about a given condition. These articles are best for patients who want a general overview
and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are
longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th
grade reading level and are best for patients who want in-depth information and are
comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to
print or e-mail these topics to your patients. (You can also locate patient education articles
on a variety of subjects by searching on “patient info” and the keyword(s) of interest.)
● Basics topics (see "Patient education: Bipolar disorder (The Basics)" and "Patient
education: Coping with high drug prices (The Basics)")
● Beyond the Basics topics (see "Patient education: Bipolar disorder (Beyond the Basics)"
and "Patient education: Coping with high prescription drug prices in the United States
(Beyond the Basics)")
These educational materials can be used as part of psychoeducational psychotherapy. (See

"Bipolar disorder in adults: Psychoeducation and other adjunctive maintenance
psychotherapies", section on 'Group psychoeducation'.)
The National Institute of Mental Health also has educational material explaining the
symptoms, course of illness, and treatment of bipolar disorder in a booklet entitled "Bipolar
Disorder," which is available online at the website or through a toll-free number, 866-615-
6464. The web site also provides references, summaries of study results in language
intended for the lay public, and information about clinical trials currently recruiting patients.
More comprehensive information is provided in many books written for patients and family
members, including The Bipolar Disorder Survival Guide: What You and Your Family Need to
Know, written by David J. Miklowitz, PhD (3rd edition, published by The Guilford Press, 2019);
An Unquiet Mind: A Memoir of Moods and Madness, written by Kay Jamison, PhD (published
by Random House, 1995); and Treatment of Bipolar Illness: A Casebook for Clinicians and
Patients, by RM Post, MD, and GS Leverich, LCSW (published by Norton Press, 2008).
The Depression and Bipolar Support Alliance ( their website or 800-826-3632) is a national
organization that educates members about bipolar disorder and how to cope with it. Other
functions include increasing public awareness of the illness and advocating for more
research and services. The organization is administered and maintained by patients and
family members, and has local chapters.
The National Alliance on Mental Illness ( their website or 800-950-6264) is a similarly

structured organization devoted to education, support, and advocacy for patients with any
mental illness. Bipolar disorder is one of their priorities.
OTHER RESOURCES
The International Society for Bipolar Disorders (ISBD) is a global organization which
fosters international collaboration in education, research, and clinical care to improve the
lives of those living with bipolar disorder and related conditions. The website provides
general resources to help educate and support patients with bipolar disorder and their
families. One of their publications is the Patient and “ Patient and Family Guide to the
CANMAT and ISBD Guidelines on the Management of Bipolar Disorder.” In addition, the
ISBD Older Adults with Bipolar Disorder task force, which focuses on improving outcomes
for older-age patients with bipolar disorder, published “A Guide for Older Adults with Bipolar
Disorders and Care Partners,” which is available online.
SUMMARY
● Definition – The minimum age used to define geriatric bipolar disorder is generally 60
years. Bipolar disorder in both geriatric and younger patients is characterized by
episodes of major depression ( table 1), mania ( table 2), and hypomania
( table 3). (See 'Definition of geriatric bipolar disorder' above.)
● Initial evaluation – Treatment for geriatric bipolar patients begins with a psychiatric
and general medical history, mental status and physical examination, and focused
laboratory and imaging studies. (See 'Initial evaluation' above.)
● Pharmacologic issues – Pharmacotherapy for older age bipolar disorder generally

requires starting the drug at a low dose, increasing the dose by small increments every
one to seven days, caution regarding side effects, and coordinating care with other
clinicians who are managing general medical comorbidity. Treatment guideline
recommendations for choosing medications for geriatric bipolar disorder are generally
similar to recommendations for younger adults, with the caveat that general medical
comorbidity and concomitant medications can render older adults more vulnerable to
adverse effects. (See 'Pharmacologic issues' above.)
● Monitoring – Compared with younger patients, geriatric bipolar patients often require
more vigilant treatment monitoring. (See 'Monitoring' above.)
● Adjunctive psychoeducation – Patients with geriatric bipolar disorder may possibly

benefit from adding group psychoeducation to pharmacotherapy. (See 'Adjunctive
psychoeducation' above.)
● Managing nonresponse – Management of acute, geriatric bipolar mood episodes that

do not respond to initial treatment generally includes verifying that the patient has
bipolar disorder rather than a different condition, asking about adherence with
treatment, determining whether there are significant life stressors that need to be
addressed, and establishing if comorbid psychopathology is present. (See 'Managing
nonresponse' above.)
● Making referrals – Primary care clinicians often treat geriatric patients with bipolar
disorder. However, the diagnosis may not be clear or these clinicians may not be
comfortable managing the disorder and thus refer patients to psychiatrists. In addition,
referral is usually indicated for patients with severe mood episodes, numerous
recurrent episodes, suicidal ideation or behavior, aggressive behavior, psychotic
features, catatonia, mixed features, poor judgment, psychiatric comorbidity,
nonresponse to treatment, or bipolar major depression. (See 'Making referrals' above.)
● Choosing specific treatments – Several specific treatments are available for geriatric
bipolar disorder. (See "Geriatric bipolar disorder: Treatment of mania and major
depression" and "Geriatric bipolar disorder: Maintenance treatment".)
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Topic 111402 Version 10.0
GRAPHICS
DSM-5-TR diagnostic criteria for bipolar major depression
A. Five (or more) of the following symptoms have been present during the same two-week period and
represent a change from previous functioning; at least one of the symptoms is either (1) depressed
mood or (2) loss of interest or pleasure.
NOTE: Do not include symptoms that are clearly attributable to another medical condition.
1. Depressed mood most of the day, nearly every day, as indicated by either subjective report
(eg, feels sad, empty, hopeless) or observations made by others (eg, appears tearful). (NOTE:
In children and adolescents can be irritable mood.)
2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day,
nearly every day (as indicated by either subjective account or observation).
3. Significant weight loss when not dieting or weight gain (eg, a change of more than 5% of
body weight in a month), or decrease or increase in appetite nearly every day. (NOTE: In
children, consider failure to make expected weight gain.)
4. Insomnia or hypersomnia nearly every day.
5. Psychomotor agitation or retardation nearly every day (observable by others, not merely
subjective feelings of restlessness or being slowed down).
6. Fatigue or loss of energy nearly every day.
7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional)
nearly every day (not merely self-reproach or guilt about being sick).
8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by their
subjective account or as observed by others).
9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a
specific plan, or a suicide attempt or a specific plan for committing suicide.
B. The symptoms cause clinically significant distress or impairment in social, occupational, or other
important areas of functioning.
C. The episode is not attributable to the direct physiological effects of a substance or to another
medical condition.
NOTE: Criteria A through C represent a major depressive episode.
NOTE: Responses to a significant loss (eg, bereavement, financial ruin, losses from a natural disaster, a
serious medical illness or disability) may include the feelings of intense sadness, rumination about the
loss, insomnia, poor appetite, and weight loss noted in Criterion A, which may resemble a depressive
episode. Although such symptoms may be understandable or considered appropriate to the loss, the
presence of a major depressive episode in addition to the normal response to a significant loss should
also be carefully considered. This decision inevitably requires the exercise of clinical judgement based
on the individual's history and the cultural norms for the expression of distress in the context of loss.
D. The occurrence of the major depressive episode is not better explained by schizoaffective disorder,
schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified
schizophrenia spectrum and other psychotic disorders.
Specify:
With anxious distress
With mixed features

With rapid cycling
With melancholic features
With atypical features
With psychotic features
With catatonia
With peripartum onset
With seasonal pattern
Adapted from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright © 2013). American
Psychiatric Association. All Rights Reserved. Note: The original diagnostic criteria remain unchanged in the Diagnostic and
Statistical Manual of Mental Disorders, Fifth Edition, Text Revision, American Psychiatric Association 2022.
Graphic 91398 Version 10.0
DSM-5-TR diagnostic criteria for manic episode
A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and
abnormally and persistently increased activity or energy, lasting at least one week and present
most of the day, nearly every day (or any duration if hospitalization is necessary).
B. During the period of mood disturbance and increased energy or activity, three (or more) of the
following symptoms (four if the mood is only irritable) are present to a significant degree and
represent a noticeable change from usual behavior:
1. Inflated self-esteem or grandiosity.
2. Decreased need for sleep (eg, feels rested after only three hours of sleep).
3. More talkative than usual or pressure to keep talking.
4. Flight of ideas or subjective experience that thoughts are racing.
5. Distractibility (ie, attention too easily drawn to unimportant or irrelevant external stimuli), as
reported or observed.
6. Increase in goal-directed activity (either socially, at work or school, or sexually) or
psychomotor agitation (ie, purposeless non-goal-directed activity).
7. Excessive involvement in activities that have a high potential for painful consequences (eg,
engaging in unrestrained buying sprees, sexual indiscretions, or foolish business
investments).
C. The mood disturbance is sufficiently severe to cause marked impairment in social or occupational
functioning or to necessitate hospitalization to prevent harm to self or others, or there are
psychotic features.
D. The episode is not attributable to the physiological effects of a substance (eg, a drug of abuse, a
medication, other treatment) or to another medical condition.
NOTE: A full manic episode that emerges during antidepressant treatment (eg, medication,
electroconvulsive therapy) but persists at a fully syndromal level beyond the physiological effect of
that treatment is sufficient evidence for a manic episode and, therefore, a bipolar I diagnosis.
NOTE: Criteria A through D constitute a manic episode. At least one lifetime manic episode is required
for the diagnosis of bipolar I disorder.
Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright © 2013).
American Psychiatric Association. All Rights Reserved. Note: These diagnostic criteria remain unchanged in the Diagnostic and
DSM-5-TR diagnostic criteria for hypomanic episode
A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and
abnormally and persistently increased activity or energy, lasting at least four consecutive days and
present most of the day, nearly every day.
B. During the period of mood disturbance and increased energy and activity, three (or more) of the
following symptoms (four if the mood is only irritable) have persisted, represent a noticeable
change from usual behavior, and have been present to a significant degree:
1. Inflated self-esteem or grandiosity.
2. Decreased need for sleep (eg, feels rested after only three hours of sleep).
3. More talkative than usual or pressure to keep talking.
4. Flight of ideas or subjective experience that thoughts are racing.
5. Distractibility (ie, attention too easily drawn to unimportant or irrelevant external stimuli), as
reported or observed.
6. Increase in goal-directed activity (either socially, at work or school, or sexually) or
psychomotor agitation.
7. Excessive involvement in activities that have a high potential for painful consequences (eg,
engaging in unrestrained buying sprees, sexual indiscretions, or foolish business
investments).
C. The episode is associated with an unequivocal change in functioning that is uncharacteristic of the
individual when not symptomatic.
D. The disturbance in mood and the change in functioning are observable by others.
E. The episode is not severe enough to cause marked impairment in social or occupational
functioning or to necessitate hospitalization. If there are psychotic features, the episode is, by
definition, manic.
F. The episode is not attributable to the physiological effects of a substance (eg, a drug of abuse, a
medication, or other treatment).
NOTE: A full hypomanic episode that emerges during antidepressant treatment (eg, medication,
electroconvulsive therapy) but persists at a fully syndromal level beyond the physiological effect of
that treatment is sufficient evidence for a hypomanic episode diagnosis. However, caution is
indicated so that one or two symptoms (particularly increased irritability, edginess, or agitation
following antidepressant use) are not taken as sufficient for a diagnosis of a hypomanic episode,
nor necessarily indicative of a bipolar diathesis.
NOTE: Criteria A through F constitute a hypomanic episode. Hypomanic episodes are common in
bipolar I disorder but are not required for the diagnosis of bipolar I disorder.
Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright © 2013).
American Psychiatric Association. All Rights Reserved. Note: These diagnostic criteria remain unchanged in the Diagnostic and
PHQ-9 depression questionnaire
Name: Date:
Over the last 2 weeks, how often have you been Not at Several More Nearly
bothered by any of the following problems? all days than every
half day
the
days
Little interest or pleasure in doing things 0 1 2 3
Feeling down, depressed, or hopeless 0 1 2 3
Trouble falling or staying asleep, or sleeping too 0 1 2 3

much
Feeling tired or having little energy 0 1 2 3
Poor appetite or overeating 0 1 2 3
Feeling bad about yourself, or that you are a failure, 0 1 2 3

or that you have let yourself or your family down
Trouble concentrating on things, such as reading the 0 1 2 3

newspaper or watching television
Moving or speaking so slowly that other people could 0 1 2 3

have noticed? Or the opposite, being so fidgety or
restless that you have been moving around a lot
more than usual.
Thoughts that you would be better off dead, or of 0 1 2 3

hurting yourself in some way
Total ___ = ___ + ___ + ___ + ___
PHQ-9 score ≥10: Likely major depression
Depression score ranges:
5 to 9: mild
10 to 14: moderate
15 to 19: moderately severe
≥20: severe
If you checked off any problems, how difficult Not Somewhat Very Extremel
have these problems made it for you to do your difficult difficult difficult difficult
work, take care of things at home, or get along at all
___ ___ ___
with other people? ___
PHQ: Patient Health Questionnaire.
Developed by Drs. Robert L Spitzer, Janet BW Williams, Kurt Kroenke, and colleagues, with an educational grant from Pfizer,
Inc. No permission required to reproduce, translate, display or distribute.

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23/2/24, 13:54 Geriatric bipolar disorder: General principles of treatment - UpToDate

Official reprint from UpToDate®

Geriatric bipolar disorder: General principles of

Literature review current through: Jan 2024.

● (See "Geriatric bipolar disorder: Epidemiology, clinical features, assessment, and

DEFINITION OF GERIATRIC BIPOLAR DISORDER

● Suicidal ideation with a specific plan and intent

● Start the drug at a low dose

A review of 34 treatment guidelines from 19 countries found that recommendations for

● A two-year randomized trial compared a group psychoeducation program plus usual

usual care included pharmacotherapy and case management. Follow-up assessments

● A prospective observational study evaluated a 12-week, adjunctive group

Managing nonresponse — If patients with geriatric bipolar disorder do not respond to

● Ask about adherence with treatment because nonadherence is common during

● Establish if comorbid psychopathology (eg, anxiety disorder, substance use disorder, or

● Severe mood episodes

● Suicidal ideation or behavior (see "Suicidal ideation and behavior in adults")

● Aggressive behavior (see "Bipolar mania and hypomania in adults: Choosing

● Psychotic features (eg, delusions or hallucinations) (see "Bipolar disorder in adults:

● Catatonia (see "Catatonia in adults: Epidemiology, clinical features, assessment, and

● Psychiatric comorbidity, such as anxiety disorders or substance use disorders (see

● Nonresponse to pharmacotherapy and psychotherapy

● Bipolar major depression ( table 1)

CHOOSING SPECIFIC TREATMENTS

SOCIETY GUIDELINE LINKS

INFORMATION FOR PATIENTS

These educational materials can be used as part of psychoeducational psychotherapy. (See

The National Alliance on Mental Illness ( their website or 800-950-6264) is a similarly

● Pharmacologic issues – Pharmacotherapy for older age bipolar disorder generally

● Adjunctive psychoeducation – Patients with geriatric bipolar disorder may possibly

● Managing nonresponse – Management of acute, geriatric bipolar mood episodes that

Use of UpToDate is subject to the Terms of Use.

8. Prabhakar D, Balon R. Late-onset bipolar disorder: a case for careful appraisal.

25. Rej S, Herrmann N, Shulman K, et al. Current psychotropic medication prescribing

sensitivity. Br J Psychiatry 1978; 133:429.

DSM-5-TR diagnostic criteria for bipolar major depression

NOTE: Criteria A through C represent a major depressive episode.

With mixed features

Graphic 91398 Version 10.0

DSM-5-TR diagnostic criteria for manic episode

Graphic 91106 Version 8.0

DSM-5-TR diagnostic criteria for hypomanic episode

Graphic 91107 Version 7.0

PHQ-9 depression questionnaire

Little interest or pleasure in doing things 0 1 2 3

Feeling down, depressed, or hopeless 0 1 2 3

Trouble falling or staying asleep, or sleeping too 0 1 2 3

Feeling tired or having little energy 0 1 2 3

Poor appetite or overeating 0 1 2 3

Feeling bad about yourself, or that you are a failure, 0 1 2 3

Trouble concentrating on things, such as reading the 0 1 2 3

Moving or speaking so slowly that other people could 0 1 2 3

Thoughts that you would be better off dead, or of 0 1 2 3

Total ___ = ___ + ___ + ___ + ___

PHQ-9 score ≥10: Likely major depression

Depression score ranges:

15 to 19: moderately severe

PHQ: Patient Health Questionnaire.

Graphic 59307 Version 12.0

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Total _ = _ + _ + _ + ___