First Line Treatments
In the case of a severe manic or mixed episode, combined pharmacological treatment with lithium plus an atypical antipsychotic such as olanzapine, risperdone, or quetiapine is the first-line treatment. For a less severe episode, monotherapy with lithium, valproate, or an atypical antipsychotic may be sufficient. Short-term adjunctive treatment with a benzodiazepine may also be helpful.
In the case of a bipolar depressive episode, lithium or lamotrigine are considered first-line treatments. Antidepressant monotherapy is not recommended, as this may trigger manic symptoms.
Augmentation of first-line pharmacological interventions with psychotherapy is also indicated. Psychological treatments with evidence of efficacy include:
- Psychoeducation about bipolar disorder. (Strong research support for mania; modest research support for depression.)
- Systemic care, in which a specialty treatment team is involved in the individual's care. Group therapy, in which individuals with BPI learn coping skills and warning signs, is also provided. (Strong research support for mania.)
- Cognitive therapy, in which the patient learns to challenge unhelpful and/or inaccurate thoughts and beliefs. (Modest research support for both mania and depression.)
- Family-focused therapy, in which families are trained to notice the emergence of symptoms, assist with medication adherence, and engage in helpful coping responses. (Strong research support for depression.)
- Interpersonal and social rhythm therapy, in which the patient learns to effectively manage sleep and other schedules implicated in symptoms. Interpersonal components, such as managing interpersonal disputes, role transitions, and interpersonal isolation, are also included. (Modest research support for depression.)
Second Line Treatments
In cases of nonresponse to first-line treatment or "breakthrough" episodes despite continued pharmacological treatment, optimization of the medication dose should be the first intervention. Re-introduction of an atypical antipsychotic may also be warranted.
During a manic episode: When first-line treatments of an optimal dose are not sufficiently effective, the addition of another first-line medication may be warranted. Alternative medications for augmentation during a manic episode include:
During a depressive episode: augmentation with an antidepressant may be considered, but the individual should be closely monitored for the emergence of manic symptoms. Adjunctive medications to be considered may include:
- Selective serotonin reuptake inhibitor (SSRI)
- Monoamine oxidase inhibitors (MAOIs)
Electroconvulsive therapy (ECT), in which small electrical currents are used to trigger a brief seizure, may also be provided as an augmentation strategy. ECT may be indicated if the individual is pregnant, in the case of severe, treatment-resistant mania or depressioin, or in the case of a mixed episode.
Additional Treatments to Consider
Preliminary evidence suggests that the following strategies, while not a substitute for the more well-validated treatments described above, might be considered to assist with depressive symptoms. However, some of these treatments have been evaluated only in the context of unipolar depression; therefore, the risk of triggering a manic episode should be carefully weighed against the potential benefits.
- A small pilot study found that augmentation of carbamazepine with Free and Easy Wanderer Plus (FEWP), which is reported to contain eleven herbal materials, was more effective than carbamazepine alone in reducing depressive but not manic symptoms in BPI.
- Omega-3 fatty acids have some support for management of bipolar depression; risk of triggering mania appears minimal.
- Herbal therapies such as St. John's Wort may be considered, although the patient should be monitored for mania symptoms.
- Acupuncture, S-adenosyl-L-methionine (SAMe), aromatherapy massage, therapeutic massage, and yoga have some modest support for reducing depressive symptoms, although these interventions have not been evaluated in BPI.