What is the recommended treatment for bipolar disorder?

Treatment of Bipolar Disorder

Lithium or valproate should be the foundation of treatment for bipolar disorder, combined with structured psychosocial interventions, and maintained for at least 2 years after the last episode. 1, 2

Pharmacological Treatment Algorithm

First-Line Mood Stabilizers

• Lithium is the gold standard treatment for bipolar disorder, effective across all phases of illness for patients age 12 and older 2
• Valproate serves as an alternative first-line agent when lithium is contraindicated or not tolerated, particularly effective for controlling manic symptoms 2
• Lithium requires close clinical and laboratory monitoring and should only be initiated where these capabilities are available 1
• Maintenance treatment must continue for at least 2 years after the last episode, with decisions to extend beyond 2 years made by a mental health specialist 1, 2

Acute Manic Episodes

• Start with lithium, valproate, and/or atypical antipsychotics to stabilize mood first 2
• Atypical antipsychotics (aripiprazole, olanzapine, risperidone, quetiapine, ziprasidone) are highly effective for acute mania and can be used as monotherapy or adjunctively with mood stabilizers 2, 3, 4
• When prescribing antipsychotics to adolescents, obtain baseline body mass index, waist circumference, blood pressure, fasting glucose, and lipid panel 2
• Prescribe antipsychotic medications one at a time 1

Depressive Episodes

• Never use antidepressants as monotherapy for bipolar depression—this is a critical pitfall 2
• For moderate to severe depressive episodes, antidepressants may be used but ALWAYS in combination with a mood stabilizer (lithium or valproate) 1, 2
• SSRIs (such as fluoxetine) are preferred over tricyclic antidepressants 1
• Lamotrigine is the preferred add-on option for patients already optimally treated with a mood stabilizer who experience breakthrough depression 2

Combination Therapy

• When using olanzapine and fluoxetine in combination for bipolar depression, start at 5 mg of olanzapine and 20 mg of fluoxetine once daily in adults 3
• For adolescents with bipolar depression, start at 2.5 mg of olanzapine and 20 mg of fluoxetine once daily 3
• Adjunctive therapy with lithium or valproate is indicated for acute manic or mixed episodes, with risperidone starting at 10 mg once daily when combined with these mood stabilizers 1, 4

Psychosocial Interventions (Essential Component)

Core Psychotherapeutic Approaches

A comprehensive, multimodal treatment approach combining pharmacotherapy with psychosocial therapies is almost always indicated, as medications help with core symptoms but do not address functional and developmental impairments 2

Evidence-Based Psychotherapies

• Family-focused therapy, child- and family-focused cognitive-behavioral therapy, and psychoeducational psychotherapy have the most empirical support for adolescents with bipolar disorder 2
• 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 1, 2
• Dialectical behavioral therapy has demonstrated efficacy at reducing depressive symptoms in adolescents with bipolar disorder, particularly those with high levels of suicidality and emotional dysregulation 2

Mandatory Psychoeducation Components

• Psychoeducation should be routinely offered to all individuals with bipolar disorder and their family members/caregivers 1
• Cover symptoms, course of the disorder, treatment options, impact on psychosocial functioning, and heritability 5, 1
• Educate about medication compliance, recognition of early relapse symptoms, and factors that precipitate relapse (sleep deprivation, substance abuse) 5, 1
• Medication noncompliance is a major contributor to relapse, requiring efforts to educate both patient and family about ongoing treatment importance 5

Relapse Prevention Strategies

• Stress reduction and promotion of stable social and sleep habits are particularly important targets 5, 1
• Establishing a strong therapeutic relationship and regular follow-up assessments improve treatment adherence 5, 1
• Family-focused therapy emphasizes treatment compliance, positive family relationships, and enhances problem-solving and communication skills 1

Functional and Developmental Support

Academic and Occupational Functioning

• Educational needs must be addressed to promote long-term academic growth, often requiring school consultation and an individual educational plan 5, 2
• Some youths will need specialized educational programs, including day treatment or partial hospitalization programs 5
• For older teenagers, vocational training and occupational support are important needs to address 5
• Supported employment may be considered for those who have difficulty obtaining or retaining employment 1

Social and Family Functioning

• Interventions to enhance independent living and social skills should be considered 1
• Therapies directed at communication and problem-solving skills are likely to be helpful 5
• Support for inclusion in economic activities appropriate to the patient's social and cultural environment should be facilitated 1

Critical Monitoring and Safety

Ongoing Assessment Requirements

• The risk of suicide is significantly elevated in bipolar disorder, requiring ongoing assessment and management throughout all phases of treatment 2
• Regular assessment of mood symptoms, medication adherence, and behaviors is essential 2
• Specific attention to metabolic parameters for patients on antipsychotics is required 2
• Regular laboratory monitoring should be conducted based on specific medications prescribed 2

Common Pitfalls to Avoid

• Using antidepressants as monotherapy for bipolar depression (always combine with mood stabilizer) 2
• Inadequate monitoring of lithium levels and metabolic parameters 2
• Failing to address psychosocial interventions alongside pharmacotherapy 2
• Premature discontinuation of maintenance treatment before 2 years 2
• Prescribing multiple antipsychotics simultaneously 1