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Goals of Treatment
to allow a return to usual levels of psychosocial functioning.
Rapidly control agitation, aggression, and
initial treatment modality.
not yet in treatment for bipolar disorder:
For severe mania or mixed episodes, initiate
lithium in combination with an antipsychotic or valproate in combination
with an antipsychotic.
For less ill patients, monotherapy
with lithium, valproate, or an antipsychotic such as olanzapine
may be sufficient.
treatment with a benzodiazepine may also be helpful.
For mixed episodes, valproate may be preferred
Second-generation (atypical) antipsychotics are preferred over first-generation (typical) antipsychotics because of their generally more tolerable
side effect profile.
Alternatives include 1) carbamazepine or
oxcarbazepine in lieu of lithium or valproate and 2) ziprasidone
or quetiapine in lieu of another antipsychotic.
Treatment selection depends on illness
severity, associated features such as rapid cycling or psychosis,
and, where possible, patient preference.
Antidepressants should be tapered and discontinued
Psychosocial therapies and pharmacotherapies
should be combined.
For patients who suffer a "breakthrough" manic
or mixed episode while on maintenance treatment, optimize the medication
serum levels are within the therapeutic range; in some instances,
achieve a higher serum level (but still within the therapeutic range).
Introduction or resumption of an antipsychotic
is often necessary.
Severely ill or agitated patients may also
require short-term adjunctive treatment with a benzodiazepine.
If symptoms are inadequately controlled
within 10 to 14 days of treatment with optimized doses of the first-line
medication regimen, add another first-line medication.
treatment options include adding carbamazepine or oxcarbazepine
in lieu of an additional first-line medication (lithium, valproate,
antipsychotic), adding an antipsychotic if not already prescribed,
or changing from one antipsychotic to another.
Clozapine may be particularly effective
in refractory illness.
Electroconvulsive therapy (ECT) may also
be considered for
- manic patients who are
severely ill or whose mania is treatment resistant;
- patients who, after
consultation with the psychiatrist, prefer ECT;
- patients with mixed
- patients with severe
mania during pregnancy.
For psychosis during a manic or mixed
episode, treat with an antipsychotic medication.
are favored because of their generally more tolerable side effect
ECT may also be considered.
of the symptoms of major depression and return the patient to usual
levels of psychosocial functioning.
Avoid precipitating a manic or hypomanic
not yet in treatment for bipolar disorder, initiate either lithium
As an alternative,
especially for more severely ill patients, consider initiating treatment
with both lithium and an antidepressant simultaneously (although
supporting data are limited).
Antidepressant monotherapy is not recommended.
Consider ECT for
- patients with life-threatening
inanition, suicidality, or psychosis or
- severe depression during
should be guided by illness severity, associated features such as
rapid cycling or psychosis, and, where possible, patient preference.
Interpersonal therapy and cognitive behavior
therapy may be useful when added to pharmacotherapy.
Although psychodynamic psychotherapy for
bipolar depression has not been empirically studied, it is widely
used in combination with medication.
For patients who suffer a breakthrough
depressive episode while on maintenance treatment, optimize the
Ensure that serum levels are within the therapeutic range;
in some instances, achieve a higher serum level (but still within
the therapeutic range).
If the patient fails to respond to optimized
maintenance treatment, consider adding lamotrigine, bupropion, or
next steps include adding another newer antidepressant (e.g., another
selective serotonin reuptake inhibitor [SSRI] or
venlafaxine) or a monoamine oxidase inhibitor (MAOI).
Tricyclic antidepressants may carry a greater
risk of precipitating a switch and are not recommended.
MAOIs may be difficult to use because of
the risk of severe drug and dietary interactions.
Psychotic features during depression usually
require adjunctive treatment with an antipsychotic medication. Some evidence suggests efficacy for antipsychotic medication (e.g., olanzapine, quetiapine) in treating non-psychotic bipolar depression.
- severe or treatment-resistant
- psychotic features,
- catatonic features.
elect to use antidepressants earlier for bipolar II depression than
for bipolar I depression because patients with bipolar II disorder
probably have lower rates of antidepressant-induced switching into
hypomania or mania.
and treat medical conditions such as hypothyroidism or drug or alcohol
use that may contribute to cycling.
If possible, taper medications (particularly
antidepressants) that may contribute to cycling.
For initial treatment, include lithium
treatment is lamotrigine.
For many patients, combinations of medications
are required (i.e., combining two of the agents above or one of
them plus an antipsychotic).
Reduce subthreshold symptoms.
Reduce suicide risk.
Reduce cycling frequency or milder degrees
of mood instability.
Improve overall function.
whether maintenance treatment is indicated.
medication is recommended following a manic or a depressive episode.
Although few maintenance studies of bipolar
II disorder have been conducted, maintenance treatment warrants
strong consideration for this form of the illness.
Choose an initial treatment modality.
with the best empirical support include lithium or valproate. Possible
alternatives include lamotrigine, carbamazepine, or oxcarbazepine.
If one of the above medications led to remission
from the most recent depressive or manic episode, it generally should
Maintenance ECT may also be considered for
patients who respond to ECT during an acute episode.
Treatment selection should be guided by
illness severity, associated features such as rapid cycling or psychosis,
and, where possible, patient preference.
Role of antipsychotics
medications should be discontinued unless they are needed for control
of persistent psychosis or prevention of recurrence of mood episodes.
Maintenance therapy with second-generation antipsychotics may be considered, but there is less evidence that their efficacy in maintenance treatment is comparable
to that of the other agents discussed above.
Role of psychosocial interventions
psychosocial interventions addressing illness management (i.e.,
adherence, lifestyle changes, and early detection of prodromal symptoms)
and interpersonal difficulties are likely to be of benefit.
Supportive and psychodynamic psychotherapies
are widely used in combination with medication.
Group psychotherapy and family therapy may
also help patients address issues such as adherence to a treatment
plan, adaptation to a chronic illness, regulation of self-esteem,
and management of marital and other psychosocial issues.
Support groups provide useful information
about bipolar disorder and its treatment.
If the patient fails to respond (i.e.,
continues to experience subthreshold symptoms or breakthrough mood
episodes), add another maintenance medication, a second-generation antipsychotic,
or an antidepressant.
There are insufficient
data to support one combination over another.