0
1
+

1. Acute Manic or Mixed Episodes

  • Goals of Treatment

    • Control symptoms to allow a return to usual levels of psychosocial functioning.

    • Rapidly control agitation, aggression, and impulsivity.

  • Choose an initial treatment modality.

    • For patients 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.

      • Short-term adjunctive treatment with a benzodiazepine may also be helpful.

      • For mixed episodes, valproate may be preferred over lithium.

      • 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 if possible.

      • Psychosocial therapies and pharmacotherapies should be combined.

    • For patients who suffer a "breakthrough" manic or mixed episode while on maintenance treatment, optimize the medication dose.

      • Ensure that 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.

    • Alternative 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 episodes; and

      • - patients with severe mania during pregnancy.

  • For psychosis during a manic or mixed episode, treat with an antipsychotic medication.

    • Second-generation antipsychotics are favored because of their generally more tolerable side effect profile.

    • ECT may also be considered.

+

2. Acute Depression

  • Goals of Treatment

    • Achieve remission of the symptoms of major depression and return the patient to usual levels of psychosocial functioning.

    • Avoid precipitating a manic or hypomanic episode.

  • Choose an initial treatment modality.

    • For patients not yet in treatment for bipolar disorder, initiate either lithium or lamotrigine.

      • 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 pregnancy.

      • Treatment selection 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 medication dosage.

      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 paroxetine.

      • Alternative 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.

      • Consider ECT for

        • - severe or treatment-resistant depression,

        • - psychotic features, or

        • - catatonic features.

      • Clinicians may 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.

+

3. Rapid Cycling

  • Identify 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 or valproate.

    • An alternative 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).

+

4. Maintenance

  • Goals of Treatment

    • Prevent relapse and recurrence.

    • Reduce subthreshold symptoms.

    • Reduce suicide risk.

    • Reduce cycling frequency or milder degrees of mood instability.

    • Improve overall function.

  • Determine whether maintenance treatment is indicated.

    • Maintenance 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.

    • Recommended options

      • Treatment options 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 be continued.

      • 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

      • Antipsychotic 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

      • Concomitant 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.

    • Maintenance ECT may also be considered for patients who respond to ECT during an acute episode.

References

NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).
Related Content
Articles
Books
The American Psychiatric Publishing Textbook of Psychiatry, 5th Edition > Chapter 11.  >
Gabbard's Treatments of Psychiatric Disorders, 4th Edition > Chapter 24.  >
Dulcan's Textbook of Child and Adolescent Psychiatry > Chapter 18.  >
The American Psychiatric Publishing Textbook of Substance Abuse Treatment, 4th Edition > Chapter 17.  >
Psychiatric News
PubMed Articles
 
  • Print
  • PDF
  • E-mail
  • Chapter Alerts
  • Get Citation