Bipolar disorder

Last updated: July 2022

Bipolar disorder is characterised by alternating manic and depressive episodes a Citation a. “Unipolar forms” are characterized by recurring episodes of depression. , generally separated by “normal” periods lasting several months or years.

Episodes of mania are characterised by elation, euphoria and hyperactivity accompanied by insomnia, grandiose ideas, and loss of social inhibitions (sexual, in particular).
Depressive episodes are often severe, with significant risk of suicide.
Look for family history of similar symptoms (particularly suicide), very frequent in bipolar patients.

Pharmacological treatment:

• Episodes of mania are treated with haloperidol PO: 5 mg once daily for 3 days, then 7.5 mg for one week; if necessary, increase by increments of 2.5 mg per week (max. 15 mg daily). 
  Possible alternatives: 
  risperidone PO: 2 mg once daily; if necessary, increase in increments of 1 mg per week (max. 6 mg daily). 
  or 
  olanzapine PO: 10 mg once daily for 3 days; if necessary, increase in increments of 5 mg per week (max. 20 mg daily). 
  If there is improvement after one week of treatment, continue with the same dose for at least 8 weeks after remission of symptoms.
• Diazepam PO (5 to 10 mg daily) can be added during the first 2 to 3 weeks.
• If symptoms do not resolve after 2 weeks of antipsychotic treatment at maximum tolerated dose (and 2 different antipsychotics have been tried), add a mood stabiliser:

valproic acid PO: 200 mg 2 times daily (Week 1) then 400 mg 2 times daily (Week 2) then 500 mg 2 times daily (Week 3). This is usually sufficient to stabilise the patient; if necessary the dose may be increased by 500 mg weekly (max. 1000 mg 2 times daily).
or
carbamazepine PO: 100 mg 2 times daily (Week 1) then 200 mg 2 times daily (Week 2) then 200 mg 3 times daily (Week 3). This is usually sufficient to stabilise the patient; if necessary the dose may be increased by 200 mg weekly (max. 1200 mg daily). 

• Treatment should be continued until at least 8 weeks after complete remission of symptoms. Assess together with the patient the benefits and risks of pursuing long-term treatment. 
• If is it decided to discontinue antipsychotic treatment, medication should be stopped gradually, monitoring for possible relapse. 
• Depressive episodes are treated as for depression (see Depression). 
• If the patient has an episode of mania while on antidepressants, immediately stop antidepressants and treat the episode of mania as above. An episode of mania while on antidepressants is indicative of bipolar disorder. 

Long-term treatment for bipolar disorder is based on continuation of the treatment that led to the remission of the manic episode: antipsychotic, mood stabilizer, or a combination of both.
Treatment can be initiated by a physician trained in mental health, but a consultation should be set up as soon as possible with a specialist. 

Valproic acid is not recommended in women of childbearing age. If it is necessary to start treatment, use carbamazepine.
If a woman of childbearing age is already taking valproic acid, switch to carbamazepine by gradually decreasing the dose of valproic acid over a period of 2 weeks (do not stop treatment abruptly) while gradually starting carbamazepine.
If a woman becomes pregnant or is planning pregnancy it is essential to contact a specialist to re-evaluate whether the treatment is still necessary and adjust the dose if needed.