How are symptoms of bipolar disorder managed?

Management of Bipolar Disorder Symptoms

Start with lithium, valproate, or atypical antipsychotics (aripiprazole, olanzapine, risperidone, quetiapine, ziprasidone) as first-line pharmacotherapy for acute mania, and always combine medication with evidence-based psychosocial interventions for optimal outcomes. 1, 2

Pharmacological Management by Phase

Acute Mania/Mixed Episodes

• Initiate lithium 5-10 mg once daily targeting serum levels of 0.8-1.2 mEq/L, or valproate starting at 125 mg twice daily titrated to 40-90 mcg/mL, or an atypical antipsychotic 1, 2, 3
• Lithium shows response rates of 38-62% in acute mania and is FDA-approved for patients age 12 and older 1, 3
• Valproate demonstrates higher response rates (53%) compared to lithium (38%) in children and adolescents with mania and mixed episodes 2
• For severe presentations with agitation or psychotic features, combine a mood stabilizer with an atypical antipsychotic rather than using monotherapy 2
• Olanzapine 10-15 mg daily provides rapid symptomatic control when combined with lithium or valproate, superior to mood stabilizers alone 4, 5

Maintenance Therapy

• Continue the regimen that successfully treated the acute episode for at least 12-24 months minimum 1, 2
• Lithium demonstrates superior evidence for preventing both manic and depressive episodes and reduces suicide attempts 8.6-fold and completed suicides 9-fold 2
• Withdrawal of maintenance lithium increases relapse risk dramatically, with over 90% of noncompliant adolescents relapsing versus 37.5% of compliant patients 1, 2
• Some individuals require lifelong treatment when benefits outweigh risks 1

Bipolar Depression

• Use olanzapine-fluoxetine combination as first-line treatment for bipolar depression 2
• Never use antidepressant monotherapy due to risk of triggering manic episodes or rapid cycling 2
• Always combine antidepressants with a mood stabilizer (lithium or valproate) to prevent mood destabilization 1, 2

Psychosocial Interventions (Essential Component)

A comprehensive multimodal approach combining pharmacotherapy with psychosocial therapies is almost always indicated and consistently shows advantages over medication alone. 1, 6

Evidence-Based Psychotherapies

• Family-focused therapy (FFT-A), child- and family-focused cognitive-behavioral therapy (CFF-CBT), and psychoeducational psychotherapy (PEP) have the strongest empirical support 1
• Dialectical behavioral therapy (DBT) demonstrates efficacy at reducing depressive symptoms and shows potential for treating high levels of suicidality and emotional dysregulation 1
• Psychotherapy added to medication doubles the time between episodes (effect size d=0.71) and improves depressive symptoms (d=0.39) 7, 6

Core Psychoeducation Elements

• Provide education to both patient and family regarding symptoms, prodromal states, course of disorder, treatment options, impact on functioning, and heritability 1, 7
• Teach symptom monitoring and self-tracking of daily mood, sleep, and other events 7
• Establish stable social and sleep routines, which is particularly important for managing bipolar symptoms 1

Monitoring Requirements

For Lithium

• Baseline: complete blood count, thyroid function tests, urinalysis, BUN, creatinine, serum calcium, and pregnancy test in females 1
• Ongoing: lithium levels, renal and thyroid function, and urinalysis every 3-6 months 1, 2

For Valproate

• Baseline: liver function tests, complete blood count, and pregnancy test 1
• Ongoing: serum drug levels, hepatic function, and hematological indices every 3-6 months 1, 2

For Atypical Antipsychotics

• Baseline: body mass index, waist circumference, blood pressure, fasting glucose, and fasting lipid panel 1, 2
• Follow-up: BMI monthly for 3 months then quarterly; blood pressure, glucose, and lipids at 3 months then yearly 1, 2
• Adolescents have increased potential for weight gain and dyslipidemia compared to adults, requiring more vigilant monitoring 4

Academic and Social Functioning Support

• Address educational needs through school consultation and individual educational plans to promote long-term academic growth 1
• Implement therapies directed at communication and problem-solving skills to enhance family and social relationships 1
• Some patients may require specialized educational programs, day treatment, or partial hospitalization 1

Special Considerations

Electroconvulsive Therapy

• Consider ECT for severely impaired patients with manic or depressive episodes in bipolar I disorder if medications are not helpful or cannot be tolerated 1

Common Pitfalls to Avoid

• Antidepressant monotherapy triggers manic episodes or rapid cycling 2
• Inadequate duration of maintenance therapy (less than 12-24 months) leads to high relapse rates 2
• Failure to monitor metabolic side effects, particularly with atypical antipsychotics 2
• Premature discontinuation of effective medications results in relapse rates exceeding 90% 1, 2
• Overlooking comorbidities such as substance use disorders, anxiety disorders, or ADHD that complicate treatment 2
• Unnecessary polypharmacy while recognizing many patients require more than one medication for optimal control 2

Medication Selection Factors

• Base choice on evidence of efficacy for the specific phase of illness, presence of complicating features, side effect profile and safety, patient's prior treatment response history, and patient and family preferences 1
• Prior positive response to a medication is a strong predictor of future response 1