From the Guidelines
Primary care providers (PCPs) treating bipolar disorder should prioritize mood stabilizers and second-generation antipsychotics as first-line treatments, while closely monitoring for suicidal ideation and adjusting medications gradually to minimize the risk of triggering mood episodes. When treating bipolar disorder, PCPs should recognize the key symptoms, including episodes of mania or hypomania and periods of depression. Initial treatment typically involves mood stabilizers such as lithium, valproate, or lamotrigine, as well as second-generation antipsychotics like quetiapine, olanzapine, or aripiprazole 1.
Key Considerations
- PCPs should monitor medication blood levels where applicable, kidney and thyroid function for lithium, liver function for valproate, and complete blood counts for most medications.
- Regular assessment for suicidal ideation is essential, as bipolar disorder carries a high suicide risk 1.
- Medication adjustments should be gradual, as abrupt changes can trigger mood episodes.
- Patient education about medication adherence, sleep hygiene, stress management, and recognizing early warning signs of mood episodes is crucial for successful management.
Treatment Approach
- 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.
- PCPs should recognize when to refer to psychiatry, particularly for complex presentations, treatment resistance, or severe symptoms requiring hospitalization.
From the FDA Drug Label
- 2 Bipolar I Disorder (Manic or Mixed Episodes) Monotherapy — Oral ZYPREXA is indicated for the acute treatment of manic or mixed episodes associated with bipolar I disorder and maintenance treatment of bipolar I disorder
When deciding among the alternative treatments available for adolescents, clinicians should consider the increased potential (in adolescents as compared with adults) for weight gain and dyslipidemia
Clinicians should consider the potential long-term risks when prescribing to adolescents, and in many cases this may lead them to consider prescribing other drugs first in adolescents [see Warnings and Precautions (5. 5)].
Key Considerations for Treating Bipolar Disorder:
- Indication: Olanzapine is indicated for the acute treatment of manic or mixed episodes associated with bipolar I disorder and maintenance treatment of bipolar I disorder.
- Adolescent Considerations: Clinicians should consider the increased potential for weight gain and dyslipidemia in adolescents compared to adults.
- Long-term Risks: Clinicians should consider the potential long-term risks when prescribing to adolescents and may consider prescribing other drugs first.
- Dosing and Administration: The dosing and administration of olanzapine for bipolar disorder should be done according to the recommended guidelines, starting with a dose of 5 to 10 mg initially, with a target dose of 10 mg/day within several days 2.
From the Research
Treatment of Bipolar Disorder
A PCP (Primary Care Physician) needs to know the following when treating bipolar disorder:
- The diagnosis and treatment of bipolar disorder requires a thorough diagnostic evaluation and a multidisciplinary approach 3
- Pharmacologic treatment underpins both short- and long-term management of bipolar disorder, with maintenance treatment to prevent relapse frequently founded on the same pharmacologic approaches that were effective in treating the acute symptoms 3
- Lithium and valproate are commonly used to treat bipolar disorder, with lithium being effective in treating acute mania and preventing both manic and depressive episodes, and valproate being more effective as an antimanic agent 4
- The choice of treatment depends on individual pretreatment variables, such as family history, previous affective episodes, and comorbidities 4
Medication Options
Some medication options for bipolar disorder include:
- Lithium: effective in treating acute mania and preventing both manic and depressive episodes, particularly 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 4
- Valproate: more effective as an antimanic agent, particularly in patients with many previous affective episodes/hospitalizations and psychiatric comorbidities 4
- Antipsychotics: such as aripiprazole, olanzapine, and quetiapine, which can be used in combination with mood stabilizers like lithium or valproate 5
- Combination therapies: such as aripiprazole+valproate, lamotrigine+valproate, and lithium+valproate, which can be effective in preventing relapse and managing symptoms 5
Patient Monitoring
Regular monitoring is essential to ensure continued symptom relief, functioning, safety, adherence, and general medical health 3
- PCPs should decide what level of intervention their practices can support and may need to train office staff, set up monitoring and follow-up systems, establish links with referral and community support services, develop therapeutic alliances with patients, and provide psychoeducation for patients and significant others 6