What are the treatment options for bipolar disorder?

From the Guidelines

The management of bipolar disorder requires a comprehensive approach combining medication, psychotherapy, and lifestyle modifications, with a focus on individualized treatment based on the specific bipolar subtype, symptom pattern, and patient preferences, as supported by the most recent study 1. The first-line pharmacological treatment typically includes mood stabilizers such as lithium (600-1200 mg/day), valproate (750-1500 mg/day), or lamotrigine (100-200 mg/day), as well as atypical antipsychotics like quetiapine (300-800 mg/day), olanzapine (5-20 mg/day), or aripiprazole (10-30 mg/day) either alone or in combination with mood stabilizers, as recommended in the practice parameter for the assessment and treatment of children and adolescents with bipolar disorder 1. Some key points to consider in the management of bipolar disorder include:

• The use of psychosocial treatments, such as family-focused treatment for adolescents, child- and family-focused cognitive behavioral therapy, and psychoeducational psychotherapy, which have been shown to be well-established and effective in improving mood symptom severity, frequency, and recovery rates, as well as secondary outcomes like improved psychosocial functioning and behavioral change 1.
• The importance of regular blood monitoring for medications like lithium and valproate to ensure safety and efficacy, with therapeutic levels of 0.6-1.2 mEq/L for lithium 1.
• The need for lifestyle management, including maintaining regular sleep patterns, avoiding substance use, managing stress, and establishing routine daily activities, to help reduce symptoms and improve overall quality of life.
• The potential benefits and risks of combining mood stabilizers with antidepressants for bipolar depression, and the need for caution when using antidepressants due to the risk of triggering manic episodes 1. Overall, the management of bipolar disorder requires a comprehensive and individualized approach that takes into account the specific needs and circumstances of each patient, with a focus on improving symptoms, functioning, and quality of life, as supported by the most recent and highest quality evidence 1.

From the FDA Drug Label

As oral formulation for the: Acute treatment of manic or mixed episodes associated with bipolar I disorder and maintenance treatment of bipolar I disorder. Adults: Efficacy was established in three clinical trials in patients with manic or mixed episodes of bipolar I disorder: two 3- to 4-week trials and one maintenance trial. Adolescents (ages 13-17): Efficacy was established in one 3-week trial in patients with manic or mixed episodes associated with bipolar I disorder Adjunct to valproate or lithium in the treatment of manic or mixed episodes associated with bipolar I disorder. Efficacy was established in two 6-week clinical trials in adults

Management of Bipolar Disorder: Olanzapine is indicated for the acute treatment of manic or mixed episodes associated with bipolar I disorder and maintenance treatment of bipolar I disorder. It can be used as an adjunct to valproate or lithium in the treatment of manic or mixed episodes associated with bipolar I disorder 2.

• Dosage: The recommended starting dose is 10 or 15 mg once daily for adults, and 2.5-5 mg once daily for adolescents, with a target dose of 10 mg/day 2.
• Risperidone is also indicated for the treatment of acute manic or mixed episodes associated with Bipolar I Disorder, as monotherapy or as adjunctive therapy with lithium or valproate 3.

From the Research

Management of Bipolar Disorder

• Bipolar disorder is a recurrent and sometimes chronic disorder of mood that affects around 2% of the world's population 4.
• The clinical manifestations of bipolar disorder can be markedly varied between and within individuals across their lifespan, making early diagnosis challenging 4.
• Over 15 approved treatments exist for the various phases of bipolar disorder, but outcomes are often suboptimal owing to insufficient efficacy, side effects, or lack of availability 4.

Treatment Options

• Lithium, the first approved treatment for bipolar disorder, continues to be the most effective drug overall, although full remission is only seen in a subset of patients 4.
• Newer atypical antipsychotics are increasingly being found to be effective in the treatment of bipolar depression; however, their long-term tolerability and safety are uncertain 4.
• Selective serotonin reuptake inhibitors (SSRIs), bupropion, tricyclic antidepressants, and monoamine oxidase inhibitors are all effective antidepressants in the management of bipolar depression, but are associated with a small risk of antidepressant-induced mood instability 5.
• Mood stabilizers, such as lithium, valproate, and lamotrigine, are recommended for long-term treatment, while antipsychotic agents, such as quetiapine, aripiprazole, asenapine, lurasidone, and cariprazine, are also recommended, but some are associated with weight gain 6.

Diagnosis and Treatment

• Bipolar disorder affects approximately 8 million adults in the US and approximately 40 million individuals worldwide, with a high prevalence of metabolic syndrome, obesity, cigarette smoking, and type 2 diabetes 6.
• Early diagnosis and treatment are associated with a more favorable prognosis, but diagnosis and optimal treatment are often delayed by a mean of approximately 9 years following an initial depressive episode 6.
• First-line therapy includes mood stabilizers, such as lithium, anticonvulsants, such as valproate and lamotrigine, and atypical antipsychotic drugs, such as quetiapine, aripiprazole, asenapine, lurasidone, and cariprazine 6.
• Pharmacotherapy with mood stabilizers, such as lithium, anticonvulsants, and antipsychotics, is a first-line treatment that should be continued indefinitely because of the risk of patient relapse 7.

Ongoing Management

• Ongoing management involves monitoring for suicidal ideation, substance use disorders, treatment adherence, and recognizing medical complications of pharmacotherapy 7.
• Psychotherapy is a useful adjunct to pharmacotherapy, and patients and their support systems should be educated about the chronic nature of this illness, possible relapse, suicidality, environmental triggers, and the effectiveness of early intervention to reduce complications 7.
• Active lifestyle approaches, including good nutrition, exercise, sleep hygiene, and proper weight management, are also important for ongoing management 7.