What is bipolar disorder?

From the Guidelines

Bipolar disorder should be treated with a combination of traditional mood stabilizers, such as lithium or valproate, and/or atypical antipsychotic medications, as these are the primary treatments for acute mania, as indicated by the practice parameter for the assessment and treatment of children and adolescents with bipolar disorder 1. The treatment of bipolar disorder is complex and typically involves a combination of medication and psychotherapy.

• The primary medications used are mood stabilizers like lithium and valproate, often combined with atypical antipsychotics such as quetiapine, olanzapine, or aripiprazole.
• These medications usually require lifelong maintenance to prevent relapse, as there are limited data on the treatment of bipolar depression and the prevention of new mood episodes 1.
• Psychotherapy approaches like cognitive behavioral therapy (CBT), interpersonal therapy, and family-focused therapy complement medication by helping patients recognize mood episode triggers, develop coping strategies, and improve relationships.
• Lifestyle modifications are also crucial, including maintaining regular sleep patterns, avoiding alcohol and recreational drugs, managing stress, and establishing routine physical activity. The term "mood stabilizer" is widely used, but most agents only have clearly demonstrated efficacy for treating acute manic symptoms in adults, thus the term "antimanic" may be a more accurate description, as noted in the practice parameter for the assessment and treatment of children and adolescents with bipolar disorder 1.
• No single agent is approved by the FDA for the treatment of all phases of bipolar disorder (acute mania, acute depression, and maintenance treatment to prevent new manic and/or depressive episodes) 1.
• Early intervention and consistent treatment significantly improve long-term outcomes and quality of life for those with bipolar disorder.

From the Research

Overview of Bipolar Disorder Treatment

• Bipolar disorder is a recurrent chronic illness distinguished by periods of mania and depression 2
• Lithium is an effective mood stabilizer used principally for the management of bipolar disorder (BD) 3

Lithium Therapy for Bipolar Disorder

• Lithium is considered a first-line intervention for maintenance treatment of bipolar disorder and strongly for the treatment of mania 3
• Lithium reduces the risk of suicide in patients with bipolar disorder 3, 4
• The ideal lithium plasma concentration for maintenance and monitoring is 0.6-0.8mmol/L 3
• Regular monitoring of renal and endocrine function is necessary when using lithium therapy 3

Dosing and Administration of Lithium

• The optimal dosing of lithium is still a subject of ongoing debate 2
• Single daily administration of lithium may minimize adverse effects and enhance compliance 2
• Alternate daily dosing may be associated with decreased adverse effects, but further research is needed 2

Clinical Considerations for Lithium Use

• Lithium may be effective in treating acute mania, and its efficacy is maximized when used to prevent both manic and depressive episodes 5
• Lithium may be a better treatment choice in patients with a positive family history for bipolar disorder, mania-depression-interval pattern, few previous affective episodes/hospitalizations, high risk for suicide, and no comorbidities 5
• Valproate may be more effective as an antimanic rather than prophylactic agent, and may be a better choice in patients with many previous affective episodes/hospitalizations and psychiatric comorbidities 5

Special Considerations and Future Research

• Further research is needed on many aspects of lithium therapy, including its use in special populations such as youth, pregnancy, and post-partum, and older adults 3
• Clear guidance on the cessation of lithium therapy is not sufficiently addressed in current clinical practice guidelines 3
• Updated perspectives on the application of lithium in mood disorders, including prophylaxis of bipolar and unipolar mood disorder, treatment of acute manic and depressive episodes, and use of lithium in pregnancy and the postpartum period, are necessary 4