From the Guidelines
The American Psychiatric Association guidelines for treating bipolar disorder recommend a comprehensive approach combining medication, psychotherapy, and lifestyle management, with first-line pharmacological treatment typically including mood stabilizers such as lithium, valproate, or lamotrigine, often in combination with second-generation antipsychotics like quetiapine, olanzapine, or aripiprazole. According to the most recent and highest quality study available, 1, the choice of medication(s) should be made based on evidence of efficacy, the phase of illness, the presence of confounding presentations, the agent's side effect spectrum and safety, the patient's history of medication response, and the preferences of the patient and his or her family.
Key Considerations for Treatment
- The primary treatment for mania in well-defined DSM-IV-TR Bipolar I Disorder is pharmacotherapy, typically including lithium, valproate, and/or atypical antipsychotic agents, with other adjunctive medications used as indicated 1.
- For acute mania, antipsychotics may be used alone or with mood stabilizers, while bipolar depression often requires combining a mood stabilizer with an antipsychotic or adding an antidepressant cautiously to prevent triggering mania 1.
- Maintenance therapy should continue for at least 2 years after symptom resolution, with many patients requiring lifelong treatment, and regular monitoring of medication blood levels, metabolic parameters, and kidney/thyroid function is essential, particularly with lithium and valproate 1.
Lifestyle Management and Psychotherapy
- Patients should maintain regular sleep schedules, avoid substance use, manage stress, and establish routine physical activity as these factors significantly impact mood stability and treatment outcomes 1.
- Psychotherapy approaches like cognitive-behavioral therapy, interpersonal therapy, and family-focused therapy should complement medication, and the patient's history of treatment response in parents may predict response in offspring 1.
Medication Options
- Lithium is approved down to age 12 years for acute mania and maintenance therapy, and other agents with some support for efficacy in adult studies include carbamazepine and antipsychotic agents 1.
- The combination of olanzapine and fluoxetine is approved for bipolar depression in adults, and other agents like valproate, lamotrigine, and topiramate have shown effectiveness in open-label trials and retrospective chart reviews for juvenile mania and bipolar depression 1.
From the Research
Overview of APA Guidelines for Treating Bipolar Disorder
- The American Psychiatric Association (APA) guidelines for treating bipolar disorder recommend a combination of pharmacotherapy and psychotherapy 2, 3.
- 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 2.
Pharmacotherapy
- Mood stabilizers, such as lithium and valproate, are effective in treating acute mania and preventing both manic and depressive episodes 4, 5.
- Antipsychotic agents, such as quetiapine, aripiprazole, asenapine, lurasidone, and cariprazine, are recommended, but some are associated with weight gain 2.
- Combination therapy with lithium and valproate may be more effective than monotherapy in preventing relapse in bipolar I disorder 6.
Treatment Strategies
- Lithium may be a better treatment choice in patients with a positive family history for bipolar disorder, mania-depression-interval pattern, few previous affective episodes/hospitalizations, high risk for suicide, and no comorbidities 5.
- Valproate may be more effective as an antimanic rather than prophylactic agent, and may be a better choice in patients with many previous affective episodes/hospitalizations and psychiatric comorbidities 5.
- Antidepressants are not recommended as monotherapy, and monotherapy with antidepressants is contraindicated during episodes with mixed features, manic episodes, and in bipolar I disorder 2, 3.
Lifestyle Approaches
- Active lifestyle approaches, including good nutrition, exercise, sleep hygiene, and proper weight management, are recommended as adjuncts to pharmacotherapy 3.
- 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 3.