Treatment of Bipolar Disorder

First-Line Treatment by Phase of Illness

The American Academy of Child and Adolescent Psychiatry recommends starting with lithium, valproate, or an atypical antipsychotic (aripiprazole, olanzapine, risperidone, quetiapine, ziprasidone) for acute mania/mixed episodes 1, 2
For severe presentations, the American Academy of Child and Adolescent Psychiatry suggests considering combination therapy with lithium or valproate plus an atypical antipsychotic 2
Lithium is FDA-approved for acute mania in patients 12 years and older, according to the Journal of the American Academy of Child and Adolescent Psychiatry 1, 2

The American Academy of Child and Adolescent Psychiatry recommends continuing the regimen that effectively treated the acute episode for at least 12-24 months 2, 3
Lithium shows superior evidence for prevention of both manic and depressive episodes, as stated by the American Academy of Child and Adolescent Psychiatry 2
Lamotrigine is approved for maintenance therapy in adults and is particularly effective for preventing depressive episodes, according to the Journal of the American Academy of Child and Adolescent Psychiatry 1, 3

The American Academy of Child and Adolescent Psychiatry recommends olanzapine-fluoxetine combination as FDA-approved for bipolar depression in adults 1, 2
Lamotrigine is effective for bipolar depression, particularly for prevention of depressive episodes, as stated by the American Academy of Child and Adolescent Psychiatry 3

For first episode of mania/mixed episode, the American Academy of Child and Adolescent Psychiatry suggests starting with lithium (if no contraindications) or valproate 2, 3
Alternative options include atypical antipsychotics (aripiprazole, olanzapine, risperidone, quetiapine, ziprasidone), as recommended by the Journal of the American Academy of Child and Adolescent Psychiatry 1, 2

Regular monitoring of medication levels, metabolic parameters, and organ function is essential, as stated by the American Academy of Child and Adolescent Psychiatry 2
For valproate, baseline monitoring should include liver function tests, complete blood count, and pregnancy test, according to the American Academy of Child and Adolescent Psychiatry 2, 3

The American Academy of Child and Adolescent Psychiatry recommends avoiding unnecessary polypharmacy while recognizing that many patients will require more than one medication for optimal control 1, 2
Antidepressant monotherapy can trigger manic episodes or rapid cycling, as stated by the Journal of the American Academy of Child and Adolescent Psychiatry 1, 2, 3
Lithium significantly reduces suicide risk (8.6-fold reduction in suicide attempt recurrence), according to the American Academy of Child and Adolescent Psychiatry 3

For adolescents (ages 13-17), the American Academy of Child and Adolescent Psychiatry recommends starting with lower doses (lithium 2.5-5 mg daily; target 10 mg/day) 1, 2
Lithium is FDA-approved for ages 12 and older, as stated by the Journal of the American Academy of Child and Adolescent Psychiatry 1, 2