What is the treatment for bipolar disorder?

Treatment of Bipolar Disorder

Bipolar disorder requires a comprehensive treatment approach combining pharmacotherapy as the primary intervention with adjunctive psychosocial therapies, with lithium or valproate serving as the foundation of maintenance treatment. 1, 2

Pharmacological Management

First-Line Mood Stabilizers

Lithium remains the gold standard treatment for bipolar disorder, effective across all phases of illness including acute mania, depression, and maintenance therapy, and is approved for patients age 12 and older. 3 However, lithium requires close clinical and laboratory monitoring and should only be initiated in settings where these monitoring capabilities are available. 2

Valproate serves as an alternative first-line agent that can effectively control manic symptoms and is particularly useful when lithium is contraindicated or not tolerated. 3

Maintenance treatment with mood stabilizers should continue for at least 2 years after the last episode, with decisions to continue beyond 2 years preferably made by a mental health specialist. 2

Atypical Antipsychotics

For acute manic episodes, atypical antipsychotics (aripiprazole, olanzapine, risperidone, quetiapine, ziprasidone) are highly effective and FDA-approved for this indication. 3, 4, 5 These agents can be used as monotherapy or adjunctively with mood stabilizers. 1

Quetiapine and olanzapine are specifically effective for bipolar depression when a patient is not currently on a mood-stabilizing agent. 6 Olanzapine is FDA-approved for bipolar I disorder treatment, including acute manic or mixed episodes and maintenance treatment. 4

When prescribing antipsychotics to adolescents, baseline monitoring is essential: body mass index, waist circumference, blood pressure, fasting glucose, and lipid panel must be obtained and monitored regularly. 3 The increased potential for weight gain and dyslipidemia in adolescents compared with adults may lead clinicians to consider other drugs first. 4

Antidepressants

For moderate to severe depressive episodes, antidepressants may be used but ALWAYS in combination with a mood stabilizer (lithium or valproate), never as monotherapy. 2 SSRIs such as fluoxetine are preferred over tricyclic antidepressants for bipolar depression. 2

When a patient is already optimally treated with a mood stabilizer and experiences breakthrough depression, lamotrigine is the preferred add-on option. 2, 6 There is limited evidence for additional benefit from antidepressants when a patient is already on a mood stabilizer, though clinicians often trial them in practice. 6

Medication Selection Algorithm

Choice of medication should be based on: 3

• Evidence of efficacy for the specific phase of illness (acute mania, depression, or maintenance)
• Presence of complicating features (psychosis, rapid cycling, mixed episodes)
• Side effect profile and safety considerations
• Patient's prior treatment response history
• Patient and family preferences

Avoid unnecessary polypharmacy while ensuring adequate coverage for both mood symptoms and behavioral concerns. 1 Antipsychotic medications should generally be prescribed one at a time. 2

Psychosocial Interventions

A comprehensive, multimodal treatment approach combining pharmacotherapy with psychosocial therapies is almost always indicated because medications help with core symptoms but do not necessarily address functional and developmental impairments. 7, 3

Evidence-Based Psychotherapies

Family-focused therapy (FFT), child- and family-focused cognitive-behavioral therapy (CFF-CBT), and psychoeducational psychotherapy (PEP) have the most empirical support for adolescents with bipolar disorder. 3 Family-focused therapy emphasizes treatment compliance, positive family relationships, and enhances problem-solving and communication skills. 7, 2

Dialectical behavioral therapy (DBT) has demonstrated efficacy at reducing depressive symptoms in adolescents with bipolar disorder and shows particular promise for those with high levels of suicidality and emotional dysregulation. 1, 3

Interpersonal and social rhythm therapy focuses on reducing stress and vulnerability by stabilizing social and sleep routines, which is particularly important for managing bipolar symptoms. 7, 2, 3

Core Psychoeducational Components

Psychoeducation should be routinely offered to all individuals with bipolar disorder and their family members/caregivers, covering: 7, 1, 2, 3

• Symptoms and course of the disorder
• Treatment options and the relationship between mood episodes and behaviors
• Impact on psychosocial and family functioning
• Heritability of the disorder
• Recognition of early relapse symptoms
• Factors that may precipitate relapse (sleep deprivation, substance abuse, medication noncompliance)

Medication noncompliance is a major contributor to relapse, requiring intensive education and support. 7 Establishing a strong therapeutic relationship and regular follow-up assessments improve treatment adherence. 2

Phase-Specific Treatment Strategies

Acute Mania

For acute mania, start with lithium, valproate, and/or atypical antipsychotics to stabilize mood first. 1 For acute agitation associated with schizophrenia or bipolar I mania, intramuscular olanzapine (10 mg, or 5-7.5 mg when clinically warranted) can be used, with assessment for orthostatic hypotension prior to subsequent dosing. 4

Bipolar Depression (De Novo or Not on Mood Stabilizer)

Quetiapine or olanzapine are first-line options, or alternatively carbamazepine and lamotrigine can be considered. 6 For combination therapy with fluoxetine, start at 5 mg of oral olanzapine and 20 mg of fluoxetine once daily in adults (2.5 mg olanzapine and 20 mg fluoxetine in adolescents). 4

Breakthrough Depression on Mood Stabilizer

If a patient is already optimally treated with lithium or another mood stabilizer, lamotrigine is the preferred add-on option. 2, 6

Maintenance Phase

Continue effective medications with regular monitoring for at least 2 years after the last episode. 2 Laboratory monitoring should be conducted based on specific medications prescribed, such as lithium levels and liver function. 1

Special Populations and Considerations

Adolescents

For adolescents with bipolar I disorder, start at lower doses: 2.5-5 mg once daily for oral olanzapine with a target of 10 mg/day, compared to 5-10 mg starting dose in adults. 4 The increased potential for weight gain and dyslipidemia in adolescents may lead clinicians to consider other drugs first. 3

Educational needs must be addressed to promote long-term academic growth, often requiring school consultation and an individual educational plan. 3 Some patients may require specialized educational programs, day treatment, or partial hospitalization. 3

Treatment-Resistant Cases

Electroconvulsive therapy (ECT) should only be considered for adolescents with well-characterized bipolar I disorder who have severe episodes of mania or depression and are nonresponsive to or unable to take standard medication therapies. 7 ECT should not be considered for cases best described as bipolar disorder NOS or atypical presentations. 7

Critical Monitoring and Safety

The risk of suicide is significantly elevated in bipolar disorder, requiring ongoing assessment and management throughout all phases of treatment. 1

Regular assessment of mood symptoms, medication adherence, and behaviors is essential, with specific attention to metabolic parameters for patients on antipsychotics. 1, 3

Common pitfalls to avoid: 7, 2

• Using antidepressants as monotherapy for bipolar depression (always combine with mood stabilizer)
• Inadequate monitoring of lithium levels and metabolic parameters
• Failing to address psychosocial interventions and focusing solely on pharmacotherapy
• Premature discontinuation of maintenance treatment before 2 years