Bipolar Affective Disorder Workup

  • Author: Stephen Soreff, MD; Chief Editor: Iqbal Ahmed, MBBS, FRCPsych (UK)   more...
 
Updated: Apr 17, 2012
 

Approach Considerations

A number of reasons exist for obtaining selected laboratory studies. First, the practitioner needs to perform the tests to determine the diagnosis. Because bipolar disorder encompasses both depression and mania and because a significant number of medical causes for each state exists, an extensive range of tests is indicated. The basic principle remains, "do not miss a treatable medical cause for the mental status."

Second, the condition necessitates use of a number of medications that require certain body systems to be working properly. For example, lithium requires an intact genitourinary (GU) system and can affect certain other systems, and certain anticonvulsants can suppress bone marrow.

Third, because bipolar illness is a lifelong disorder, performing certain baseline studies is important to establish any long-term effects of the medications.

A number of infections, especially chronic infections, can produce a presentation of depression in the patient. Any of the encephalitides can dramatically manifest as changes in mental status.

For more information, see Pediatric Bipolar Affective Disorder.

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Blood Studies

Complete blood count

A complete blood count (CBC) with differential is used to rule out anemia as a cause of depression. Treatment, especially with certain anticonvulsants, may depress the bone marrow—hence the need to check the red blood cell (RBC) and white blood cell (WBC) counts for signs of bone marrow suppression. Lithium may cause a reversible increase in the WBC count.

Erythrocyte sedimentation rate

The erythrocyte sedimentation rate (ESR) is determined to look for any underlying disease process such a lupus or an infection. An elevated ESR would indicate such a disease process.

Fasting glucose

The fasting glucose level is measured to rule out diabetes. Atypical antipsychotics have been associated with weight gain and problems with blood glucose regulation in patients with diabetes.

Electrolytes

Serum electrolyte concentrations are measured to help diagnose problems, especially with sodium, that are related to depression. Hyponatremia (ie, low sodium) can manifest as a depression. Treatment with lithium can lead to renal problems and electrolyte problems. Low sodium levels can lead to higher lithium levels and lithium toxicity. Hence, in screening candidates for lithium therapy as well as those on lithium therapy, checking electrolytes is indicated.

Calcium

Serum calcium is assessed to diagnose hypercalcemia and hypocalcemia associated with mental status changes (eg, hyperparathyroidism). Hyperparathyroidism, as evidenced by an elevated calcium blood level, produces depression. Certain antidepressants, such as nortriptyline, affect the heart; therefore, checking calcium levels is important.

Proteins

Low serum protein levels found in patients who are depressed may be a result of not eating. Low serum protein levels increase the availability of certain medications because these drugs have less protein to which to bind.

Thyroid hormones

Thyroid tests are performed to rule out hyperthyroidism (mania) and hypothyroidism (depression). Treatment with lithium can cause hypothyroidism, which may also contribute to the rapid cycling of mood.

Creatinine and blood urea nitrogen

Kidney failure can present as depression. Treatment with lithium can affect urinary clearances, and serum creatinine and blood urea nitrogen (BUN) levels can increase. Therefore, carefully and regularly monitor these levels.

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Substance and Alcohol Screening

Alcohol abuse and abuse of a wide variety of drugs can present as either mania or depression. For example, speed (ie, amphetamines) and cocaine abuse can present as a manialike disorder, and barbiturate abuse can present as a depressionlike disorder.

A number of patients with bipolar affective disorder also have a drug or alcohol addiction; therefore, they have dual diagnoses. Performing a substance screen helps make this dual diagnosis. If the patient has a dual diagnosis, monitoring for these substances is important.

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Other Laboratory Tests

Urine copper level testing is used to rule out Wilson disease, which produces mental changes. This disease is a rare condition that is easily missed.

Antinuclear antibody testing is used to rule out lupus.

An HIV test may be helpful. AIDS causes changes in mental status, including dementia and depression.

A Venereal Disease Research Laboratory (VDRL) test may be indicated. Syphilis, especially in its later stage, alters mental status.

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Magnetic Resonance Imaging

The total value of performing magnetic resonance imaging (MRI) in a patient with bipolar disorder remains unclear; however, a couple of reasons do exist for performing an imaging study. Because manic-depressive illness is a lifelong disease, a strong battery of studies rules out any other medical etiology and establishes a baseline. Some investigators report that patients with mania have hyperintensity in their temporal lobes.

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Electrocardiography

Many of the antidepressants, especially the tricyclics and some of the antipsychotics, can affect the heart and cause conduction problems. Lithium also can lead to changes such as reversible flattening or inversion of T waves on electrocardiography (ECG). A pretreatment ECG is important.

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Electroencephalography

The reasons for ordering electroencephalography (EEG) in patients with bipolar illness are as follows:

  • EEG provides a baseline and helps rule out any neurologic problems. Use this test to rule out a seizure disorder and brain tumor.
  • If electroconvulsive therapy (ECT) is contemplated, an EEG may be helpful. EEG monitoring during ECT is used to determine the occurrence and duration of seizure.
  • Some studies have shown that abnormalities in EEG findings have been indicative of anticonvulsant effectiveness. Specifically, an abnormal EEG finding may predict the response to valproate.
  • Some patients may have seizures when on medications, especially antidepressants. In addition, lithium can cause diffuse slowing.
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Contributor Information and Disclosures
Author

Stephen Soreff, MD  President of Education Initiatives, Nottingham, NH; Faculty, Metropolitan College of Boston University, Boston, MA

Stephen Soreff, MD is a member of the following medical societies: American College of Mental Health Administration and American Psychosomatic Society

Disclosure: Nothing to disclose.

Coauthor(s)

Lynne Alison McInnes, MD, MS  Associate Clinical Professor of Psychiatry, University of California, San Francisco, School of Medicine; Associate Adjunct Professor of Psychiatry and Genetics and Genomic Sciences, Department of Psychiatry and Human Genetics, Mount Sinai School of Medicine

Lynne Alison McInnes, MD, MS is a member of the following medical societies: Alpha Omega Alpha, American Psychiatric Association, and American Society of Human Genetics

Disclosure: Nothing to disclose.

Chief Editor

Iqbal Ahmed, MBBS, FRCPsych (UK)  Faculty, Department of Psychiatry, Tripler Army Medical Center; Clinical Professor of Psychiatry, Uniformed Services University of Health Sciences: Clinical Professor of Psychiatry, Clinical Professor of Geriatric Medicine, University of Hawaii, John A Burns School of Medicine

Iqbal Ahmed, MBBS, FRCPsych (UK) is a member of the following medical societies: Academy of Psychosomatic Medicine, American Association for Geriatric Psychiatry, American Neuropsychiatric Association, American Psychiatric Association, American Society of Clinical Psychopharmacology, and Royal College of Psychiatrists

Disclosure: Nothing to disclose.

Additional Contributors

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

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Table. FDA-Approved Bipolar Treatment Regimens
Generic NameTrade NameManicMixedMaintenanceDepression
ValproateDepakoteX
Carbamazepine extended releaseEquetroXX
LamotrigineLamictalX
LithiumXX
AripiprazoleAbilifyXXX
ZiprasidoneGeodonXX
RisperidoneRisperdalXX
AsenapineSaphrisXX
QuetiapineSeroquelXX
ChlorpromazineThorazineX
OlanzapineZyprexaXXX
Olanzapine/fluoxetine combinationSymbyaxX
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