Treatment of Bipolar Disorder

Initial Treatment

• The American College of Physicians recommends starting with a mood stabilizer (lithium or valproate) plus an antipsychotic for rapid control of symptoms in patients with acute bipolar manic episodes 1

Maintenance Treatment

• The American Psychiatric Association suggests continuing mood stabilizer for at least 2 years after the last episode to prevent recurrence of manic episodes 1
• The American Psychiatric Association recommends continuing antipsychotic treatment for at least 12 months after remission to maintain stability in patients with bipolar disorder 1
• Lithium or valproate are effective for maintenance treatment of bipolar disorder, as recommended by the PLoS Medicine study 1
• Maintenance treatment should be continued for at least 2 years after the last episode to minimize the risk of relapse, and selective serotonin reuptake inhibitors (SSRIs) should only be used in combination with a mood stabilizer for moderate to severe depressive episodes 1, 2

Psychotherapy and Education

• Psychoeducation for patients and families should be routinely offered to improve outcomes and management of bipolar disorder 1
• Cognitive behavioral therapy and family interventions can improve outcomes in patients with bipolar disorder, according to the American Psychological Association 1
• Cognitive-behavioral therapy is effective for depression in elderly patients, as suggested by the American Geriatrics Society 3
• Cognitive intervention strategies, including domain-specific interventions, global strategies, compensatory and remedial approaches, psychoeducation, and family support, can improve cognitive outcomes in individuals with cognitive impairment, as recommended by the American Academy of Child and Adolescent Psychiatry 4, 5

Medication Management

• Quetiapine or aripiprazol in low doses are effective for depression with bipolar features, with quetiapine starting at 12.5-25 mg at night and aripiprazol starting at 2 mg/day, as recommended by the American Psychiatric Association 6
• Aripiprazol has a more favorable metabolic profile, according to the American Psychiatric Association 6
• Lamotrigine is considered the safest mood stabilizer due to its favorable side effect profile and low risk of arrhythmia, metabolic effects, and organ toxicity, as classified by the European Society of Cardiology 7
• Antidepressants should always be used in combination with a mood stabilizer or an antipsychotic to prevent triggering manic episodes, as recommended by guidelines 1

Monitoring and Prevention

• Metabolic disturbances require regular monitoring of weight, blood sugar, and lipid profile, as recommended by the American Psychiatric Association 6
• Cognitive impairment should be managed by minimizing anticholinergic burden, according to the American Psychiatric Association 6
• The following parameters should be monitored regularly:

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• Unintentional weight gain >2 kg in a month or ≥7% increase from baseline body weight warrants attention, and metformin may be considered in some cases to counteract medication-induced weight gain, according to the American Medical Association 8
• Regular physical activity (150-300 minutes/week of moderate activity), regular sleep schedule, stress reduction, and avoidance of substances that may trigger episodes are recommended for weight management, as suggested by the American Medical Association and the American Academy of Family Physicians 8, 9

Associated Risks and Considerations

• Bipolar disorder is associated with increased risk of metabolic syndrome, obesity, type 2 diabetes, and cardiovascular disease, and regular monitoring of these parameters is essential, as recommended by the American Psychiatric Association 10
• Certain medications, including mood stabilizers, can affect gingival tissues, though the frequency of such effects may vary among different medications, with carbamazepine being less commonly reported than other mood stabilizers 7
• Certain medications, including SSRIs, antipsychotics, antidepressants, and mood stabilizers, are associated with weight gain, according to the American Gastroenterological Association and the American College of Physicians 11, 10, 12, 13
• The following medications are associated with more anticholinergic effects and a greater risk of agitation in the elderly population: paroxetine, fluoxetine, and tertiary-amine TCAs, according to the American Psychiatric Association and the American Geriatrics Society 14