From the Guidelines
Treatment for bipolar disorder typically involves a combination of medication, psychotherapy, and lifestyle management, with the primary goal of reducing morbidity, mortality, and improving quality of life. The primary medications used include mood stabilizers like lithium (600-1200 mg daily), valproate (750-1500 mg daily), and lamotrigine (100-200 mg daily); atypical antipsychotics such as quetiapine (300-800 mg daily), olanzapine (5-20 mg daily), and aripiprazole (10-30 mg daily); and sometimes antidepressants (used cautiously and typically with mood stabilizers) 1.
Medication Management
These medications help regulate neurotransmitters and neural pathways involved in mood regulation. The choice of medication(s) should be made based on evidence of efficacy, the phase of illness, the presence of confounding presentations, the agent's side effect spectrum and safety, the patient's history of medication response, and the preferences of the patient and his or her family 1.
Psychotherapy Approaches
Psychotherapy approaches include:
- Cognitive behavioral therapy (CBT)
- Interpersonal and social rhythm therapy (IPSRT)
- Family-focused therapy These therapies help patients recognize triggers, develop coping strategies, and improve relationships 1.
Lifestyle Management
Lifestyle management is crucial and involves:
- Maintaining regular sleep patterns
- Avoiding alcohol and recreational drugs
- Managing stress
- Exercising regularly
- Establishing a routine Treatment is typically long-term, with medication adjustments as needed based on symptoms and side effects 1.
Regular Monitoring
Regular monitoring by healthcare providers is essential, as is medication adherence even when feeling well, since stopping treatment often leads to relapse. In cases where medications are not effective or cannot be tolerated, electroconvulsive therapy (ECT) may be considered for severely impaired adolescents with manic or depressive episodes in bipolar I disorder 1.
Special Considerations
For bipolar disorder NOS, treatment generally involves the combination of psychopharmacology with behavioral/psychosocial interventions, with strategies based on the specific symptom presentations of the child, comorbid conditions, and family needs 1. Mood stabilizers and atypical antipsychotics are often used to help control severe mood lability and explosive outbursts, and other medications such as stimulants and antidepressants may be used to treat comorbid ADHD or associated depression.
From the FDA Drug Label
1.2 Bipolar I Disorder (Manic or Mixed Episodes)
Monotherapy Oral olanzapine is indicated for the acute treatment of manic or mixed episodes associated with bipolar I disorder and maintenance treatment of bipolar I disorder Efficacy was established in three clinical trials in adult patients with manic or mixed episodes of bipolar I disorder: two 3- to 4-week trials and one monotherapy maintenance trial.
1.5 Olanzapine and Fluoxetine in Combination: Depressive Episodes Associated with Bipolar I Disorder
Oral olanzapine and fluoxetine in combination is indicated for the treatment of depressive episodes associated with bipolar I disorder, based on clinical studies.
- Treatment options for bipolar disorder include:
- Monotherapy with olanzapine for the acute treatment of manic or mixed episodes associated with bipolar I disorder and maintenance treatment of bipolar I disorder 2
- Adjunctive therapy with olanzapine to lithium or valproate for the treatment of manic or mixed episodes associated with bipolar I disorder 2
- Olanzapine and fluoxetine in combination for the treatment of depressive episodes associated with bipolar I disorder 2
- Monotherapy with risperidone for the treatment of acute manic or mixed episodes associated with Bipolar I Disorder 3
- Risperidone adjunctive therapy with lithium or valproate for the treatment of acute manic or mixed episodes associated with Bipolar I Disorder 3
From the Research
Treatment Options for Bipolar Disorder
The treatment options for bipolar disorder include:
- Mood stabilizers, such as lithium, valproate, and lamotrigine 4
- Antipsychotic agents, such as quetiapine, aripiprazole, asenapine, lurasidone, and cariprazine 4
- Anticonvulsants, such as carbamazepine and valproic acid (sodium valproate) 5
- Antidepressants, although not recommended as monotherapy 4
First-Line Therapy
First-line therapy for bipolar disorder includes:
- Mood stabilizers, such as lithium 6, 4, 7
- Anticonvulsants, such as valproate and lamotrigine 4
- Atypical antipsychotic drugs, such as quetiapine, aripiprazole, asenapine, lurasidone, and cariprazine 4
Lithium Therapy
Lithium is considered the gold standard drug for bipolar disorder 6 and is effective in the prophylaxis of manic, depressive, and suicidal symptoms 6. Lithium therapy is also associated with a variety of adverse drug reactions and the need for therapeutic drug monitoring 6. Lithium is a safe and effective treatment option for children, although risperidone and quetiapine may be considered as alternative treatment options in some cases 6.
Combination Therapy
Combination therapy, such as lithium plus adjunctive therapy, may be effective in improving treatment outcomes 6, 8. However, the use of adjunctive antidepressants should be limited to episodes of breakthrough depression 7.
Long-Term Treatment
The major objective of long-term treatment is to reduce the frequency of episodes of mania and depression 5. Regular monitoring of lithium plasma concentrations is required to ensure that the range of 0.5 to 0.9 mmol/L is not exceeded 5. Psychological treatment and patient education have been shown to improve outcome, and should be made more widely available to all patients with bipolar disorder 5.