Treatment of Bipolar Disorder

Pharmacological Management

The American Academy of Child and Adolescent Psychiatry recommends pharmacotherapy with mood stabilizers, including lithium, valproate, and/or atypical antipsychotics, as the primary treatment for bipolar disorder, with the specific choice based on the phase of illness, efficacy evidence, side effect profile, and patient history 1, 2
For bipolar mania, first-line options include lithium, valproate, or carbamazepine, with haloperidol or second-generation antipsychotics as alternatives, according to the American Academy of Child and Adolescent Psychiatry 3, 4
Lithium is FDA-approved for acute mania treatment and has the most evidence for long-term prophylaxis, with a recommendation for use in patients with bipolar disorder, as stated by the American Academy of Child and Adolescent Psychiatry 1, 2
Atypical antipsychotics approved for acute mania in adults include aripiprazole, olanzapine, risperidone, quetiapine, and ziprasidone, as approved by the FDA and recommended by the American Academy of Child and Adolescent Psychiatry 2
Benzodiazepines may be used short-term to manage acute agitation and sleep disturbance in adults, but may cause disinhibition in younger patients, according to the American Academy of Child and Adolescent Psychiatry 1

Maintenance therapy should continue for at least 2 years after the last episode, with lithium or valproate as first-line options, as recommended by the American Academy of Child and Adolescent Psychiatry 3, 5
Studies show that more than 80% of patients with a manic episode will relapse without maintenance treatment, highlighting the importance of ongoing therapy, as reported by the American Academy of Child and Adolescent Psychiatry 6
Lamotrigine and olanzapine are FDA-approved for maintenance therapy in adults, and most patients will require ongoing medication therapy to prevent relapse, according to the American Academy of Child and Adolescent Psychiatry 2, 6

For depressive episodes, antidepressants may be used but only in combination with a mood stabilizer, such as lithium or valproate, to prevent triggering mania, as recommended by the American Academy of Child and Adolescent Psychiatry 3, 8
SSRIs, such as fluoxetine, are preferred over tricyclic antidepressants for bipolar depression, and the combination of olanzapine and fluoxetine is FDA-approved for bipolar depression in adults, as stated by the American Academy of Child and Adolescent Psychiatry 2, 3, 8

Before starting lithium, baseline tests, including CBC, thyroid function tests, urinalysis, BUN, creatinine, serum calcium, and pregnancy test in females, are recommended by the American Academy of Child and Adolescent Psychiatry 7
For valproate, baseline liver function tests, CBC, and pregnancy test are recommended, and for atypical antipsychotics, monitoring of BMI, blood pressure, fasting glucose, and lipids is necessary, as stated by the American Academy of Child and Adolescent Psychiatry 7
Atypical antipsychotics are associated with significant weight gain and metabolic problems, such as diabetes and hyperlipidemia, according to the American Academy of Child and Adolescent Psychiatry 7

Electroconvulsive therapy may be considered for severely impaired patients with mania or depression who don't respond to or cannot tolerate medications, as recommended by the American Academy of Child and Adolescent Psychiatry 9, 7
Avoid unnecessary polypharmacy by discontinuing agents that haven't demonstrated significant benefit, as stated by the American Academy of Child and Adolescent Psychiatry 7

Psychoeducation should be routinely offered to individuals with bipolar disorder and their family members/caregivers, and cognitive behavioral therapy and family interventions should be considered, as recommended by the American Academy of Child and Adolescent Psychiatry 3, 10
A comprehensive, multimodal treatment approach combining pharmacotherapy with psychosocial therapies is almost always indicated, according to the American Academy of Child and Adolescent Psychiatry 9