What is the recommended treatment for bipolar disorder?

Treatment for Bipolar Disorder

Start with lithium or valproate as the foundation of maintenance treatment for bipolar disorder, continuing for at least 2 years after the last episode, and always combine mood stabilizers with antidepressants when treating depressive episodes. 1

Pharmacological Treatment Algorithm

First-Line Maintenance Treatment

• Lithium or valproate are the recommended foundational mood stabilizers for long-term management of bipolar disorder 1
• Lithium remains the most effective drug overall for bipolar disorder, though it requires close clinical and laboratory monitoring and should only be initiated where these capabilities exist 1, 2
• Maintenance treatment must continue for at least 2 years after the last episode, with decisions to extend beyond 2 years preferably made by a mental health specialist 1

Acute Episode Management

For Manic or Mixed Episodes:

• Start with 10-15 mg daily of olanzapine in adults, or 2.5-5 mg daily in adolescents (ages 13-17), targeting 10 mg/day 3, 4
• Risperidone is FDA-approved for acute manic or mixed episodes in both adults and children/adolescents (ages 10-17) 5
• Second-generation antipsychotics (aripiprazole, olanzapine, risperidone, quetiapine, ziprasidone) are effective for acute management if availability and cost permit 1, 3
• Prescribe antipsychotic medications one at a time 1

For Depressive Episodes:

• Never use antidepressants as monotherapy—always combine with lithium or valproate 1
• SSRIs (such as fluoxetine) are preferred over tricyclic antidepressants 1
• For moderate to severe depression, start with 5 mg olanzapine plus 20 mg fluoxetine once daily in adults, or 2.5 mg olanzapine plus 20 mg fluoxetine in adolescents 4

For Adjunctive Treatment with Lithium or Valproate:

• Start olanzapine at 10 mg once daily when combining with existing mood stabilizers 4
• Risperidone adjunctive therapy with lithium or valproate is FDA-approved for acute manic or mixed episodes 5

Special Populations

Adolescents (ages 13-17):

• Pharmacotherapy is the primary treatment for well-defined bipolar I disorder, typically including lithium, valproate, and/or atypical antipsychotics 3
• Monitor baseline and ongoing body mass index, waist circumference, blood pressure, fasting glucose, and lipid panel for those on antipsychotics 3
• The increased potential for weight gain and dyslipidemia in adolescents compared with adults should inform medication selection 4

Psychosocial Interventions (Essential Adjuncts)

Core Psychoeducation

• Routinely offer psychoeducation to all patients and their family members/caregivers covering symptoms, course, treatment options, impact on functioning, and heritability 1
• Education about medication compliance, recognition of early relapse symptoms, and precipitating factors (sleep deprivation, substance abuse) is crucial 1

Evidence-Based Psychotherapies

For Adults:

• Cognitive behavioral therapy and family interventions should be considered when trained professionals are available 1
• Family-focused therapy emphasizes treatment compliance, positive family relationships, and enhances problem-solving and communication skills 1
• Interpersonal and social rhythm therapy focuses on stabilizing social and sleep routines to reduce stress and vulnerability 1

For Adolescents:

• A comprehensive, multimodal approach combining pharmacotherapy with psychosocial therapies is almost always indicated 3
• Family-focused therapy (FFT-A), child- and family-focused cognitive-behavioral therapy (CFF-CBT), and psychoeducational psychotherapy (PEP) have the most empirical support 3
• Dialectical behavioral therapy has demonstrated efficacy at reducing depressive symptoms and shows potential for high suicidality and emotional dysregulation 3

Functional Support

• Address educational needs through school consultation and individual educational plans to promote long-term academic growth 3
• Interventions to enhance independent living and social skills should be considered 1
• Supported employment may be considered for those with difficulty obtaining or retaining employment 1

Critical Monitoring and Follow-Up

Therapeutic Relationship

• Establishing a strong therapeutic relationship and regular follow-up assessments improve treatment adherence 1
• Stress reduction and promotion of stable social and sleep habits are particularly important targets 1

Metabolic Monitoring for Antipsychotics

• For adolescents taking antipsychotics, monitor baseline body mass index, waist circumference, blood pressure, fasting glucose, and lipid panel 3
• Assess for orthostatic hypotension prior to subsequent dosing with intramuscular olanzapine 4

Common Pitfalls to Avoid

• Never prescribe antidepressants as monotherapy for bipolar depression—this is contraindicated and risks precipitating manic episodes 1, 6
• Do not discontinue mood stabilizers prematurely; maintain for at least 2 years after the last episode 1
• Avoid prescribing multiple antipsychotics simultaneously 1
• Do not initiate lithium without adequate monitoring capabilities in place 1
• Recognize that monotherapy often provides only partial relief; combination therapy is frequently necessary 2, 7

Special Considerations

Electroconvulsive Therapy:

• May be considered for severely impaired adolescents with manic or depressive episodes in bipolar I disorder if medications are not helpful or cannot be tolerated 3

Lower Starting Doses:

• Recommended in debilitated or pharmacodynamically sensitive patients, those with predisposition to hypotensive reactions, or with potential for slowed metabolism 4