Treatment of Bipolar Disorder
Lithium is the gold standard treatment for bipolar disorder, effective across all phases of illness for patients age 12 and older, and should be the first-line pharmacological agent unless contraindicated. 1
Pharmacological Management by Phase
Acute Mania Treatment
- Start with lithium, valproate, and/or atypical antipsychotics to stabilize mood first. 1
- Valproate serves as an alternative first-line agent when lithium is contraindicated or not tolerated, particularly effective for controlling manic symptoms. 1
- Atypical antipsychotics (aripiprazole, olanzapine, risperidone, quetiapine, ziprasidone) are highly effective for acute manic episodes and can be used as monotherapy or adjunctively with mood stabilizers. 1, 2, 3
- For adults, start with 10-15 mg daily of oral olanzapine or 10 mg intramuscular for acute agitation. 2
- For adolescents with acute mania, start at 2.5-5 mg daily with a target of 10 mg/day. 1, 4
Bipolar Depression Treatment
- Antidepressants must NEVER be used as monotherapy for bipolar depression—always combine with a mood stabilizer (lithium or valproate). 1, 5
- SSRIs (such as fluoxetine) are preferred over tricyclic antidepressants when antidepressants are indicated. 5
- Lamotrigine is the preferred add-on option for patients already optimally treated with a mood stabilizer who experience breakthrough depression. 1
- For moderate to severe depressive episodes in bipolar I disorder, start with 5 mg olanzapine combined with 20 mg fluoxetine once daily in adults (2.5 mg olanzapine with 20 mg fluoxetine in adolescents). 2
Maintenance Treatment
- Continue effective medications with regular monitoring for at least 2 years after the last episode. 1, 5
- Decisions to continue maintenance treatment beyond 2 years should preferably be made by a mental health specialist. 1, 5
- Lithium or valproate form the foundation of maintenance treatment for both bipolar I and bipolar II disorder. 5
- Lithium requires close clinical and laboratory monitoring and should only be initiated in settings where these monitoring capabilities are available. 5
Psychosocial Interventions (Essential Component)
A comprehensive, multimodal treatment approach combining pharmacotherapy with psychosocial therapies is almost always indicated, as medications help with core symptoms but do not necessarily address functional and developmental impairments. 1, 4
Evidence-Based Psychotherapies
- Family-focused therapy (FFT-A), child- and family-focused cognitive-behavioral therapy (CFF-CBT), and psychoeducational psychotherapy (PEP) have the most empirical support for adolescents with bipolar disorder. 1, 4
- 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. 1, 4
- 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, 4
- Psychoeducation should be routinely offered to all individuals with bipolar disorder and their family members/caregivers, covering symptoms, course of the disorder, treatment options, impact on psychosocial functioning, and heritability. 5, 4
Special Population Considerations
Adolescents (Ages 12-17)
- Pharmacotherapy is the primary treatment for adolescents with well-defined bipolar I disorder, typically including lithium, valproate, and/or atypical antipsychotic agents. 4
- When prescribing antipsychotics to adolescents, baseline monitoring is essential, including body mass index, waist circumference, blood pressure, fasting glucose, and lipid panel. 1, 4
- Educational needs must be addressed to promote long-term academic growth, often requiring school consultation and an individual educational plan. 1, 4
- The increased potential for weight gain and dyslipidemia in adolescents compared with adults may lead clinicians to consider prescribing other drugs first. 2
Combination Therapy
- Adjunctive therapy with lithium or valproate plus atypical antipsychotics is indicated for acute manic or mixed episodes when monotherapy is insufficient. 1, 3
- For bipolar I disorder with lithium or valproate, start olanzapine at 10 mg once daily. 2
- Antipsychotic medications should generally be prescribed one at a time. 5
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. 1
- Regular assessment of mood symptoms, medication adherence, and behaviors is essential, with specific attention to metabolic parameters for patients on antipsychotics. 1
- Laboratory monitoring should be conducted based on specific medications prescribed, with lithium requiring particularly close clinical and laboratory monitoring. 1, 5
Common Pitfalls to Avoid
- Using antidepressants as monotherapy for bipolar depression (this can precipitate manic episodes). 1
- Inadequate monitoring of lithium levels and metabolic parameters. 1
- Failing to address psychosocial interventions alongside pharmacotherapy. 1
- Premature discontinuation of maintenance treatment before 2 years. 1
- Prescribing multiple antipsychotics simultaneously. 5