Bipolar disorder

Bipolar disorder is characterised by alternating manic and depressive episodes1 , 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.
Search family history of similar symptoms (particularly suicide), very frequent in bipolar patients.

– Episodes of mania are treated with risperidone PO starting at a low dose (2 mg once daily), increase if necessary in steps of 1 mg daily (max. 6 mg daily) or haloperidol PO (5 to 15 mg daily) for 3 to 6 weeks.
– Diazepam PO (5 mg daily) can be added during the first weeks.
– At the end of antipsychotic treatment, medication should be stopped gradually, monitoring for possible relapse. Continue treatment if necessary. 
– Depressive episodes are treated as 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.

The primary treatment for bipolar disorder is a mood stabilizer taken for life. 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 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).
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). 

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.

Ref Notes
1 “Unipolar forms” are characterized by recurring episodes of depression.