Bipolar Disorder

Clinical Practice Guideline Summary for Primary Care

DIAGNOSIS AND CLINICAL ASSESSMENT
The fundemental problem for persons with Bipolar Disorder is that their typicaly mood
cycles are more extreme: they may be euphoric for periods of time and engage in reckless
behaviors during periods of mania. This may be followed by a grinding depression that
may also be charaterized by self-destructive impulses or behaviors. Bipolar I Disorder
requries the history of at least one manic episode, whereas Bipolar II Disorder may carry
similiar mood extremes without a history of mania. It is important to distinguish Bipolar
Disorder from substance use disorder (e.g. cocaine abuse) or medical conditions (e.g.
hyperthyroidism) that may mimic a similar course of mood swings. The medical
management of bipolar disorder consists of a broad array of interventions and activities.
Regardless of the modalities selected, it is important to provide medical management
through all phases of treatment. A diagnostic evaluation includes assessment of:

Personal safety and safety of others

Level of functional impairment and capacity for self-care
Best treatment setting given presenting symptoms
Plan for monitoring the mental status and improvement
Education for the patient and family/support system about treatment adherence,
promoting regular patterns of activity and of sleep.

It is critical to assess suicide risk initially and throughout the course of treatment. The
risk of suicide in patients recovering from depression increases transiently as they
develop the energy and capacity to act on self-destructive plans made earlier. The risk of
suicide in manic patients is high due to agitation and impulsivity, and the risk remains
high when the manic episode has ended due to the acute loss of elation.
POTENTIAL WARNING SIGNS IN TREATING PATIENTS WITH BIPOLAR
DISORDER
Any significant or sudden change in mental status, such as a new onset of self
destructive behaviors or violent behaviors, warrents at least consultation with a
behavioral health colleague and may require urgent or emergent treatment
including hospitalization.
Examples of patients who may require hospitalization include those with
comorbid depression who are at risk of suicide, or patients with comorbid
substance use disorders requiring detoxification.
Emergence of risky behaviors (excessive spending; hyper sexual impulses,
other impulsive acts that put the member at risk), warrants consultation with a
behavioral health provider. The extreme points in a persons mood cycle may
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March 2009
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Clinical practice summaries are intended to guide treatment for patients with a specific behavioral health
disorder. This summary is not meant to substitute for individualized evaluation and treatment specific to
the members needs.

require brief hospitalization in order to assess safety and containment, as well as

adjust medication in 24 hours supervised setting.

EFFECTIVE TREATMENT
The goal of treatment of Bipolar Disorder is to significantly decrease symptoms and the
impairment of the mood cycles. Goals of treatment may include monitoring medication
compliance, monitoring the patients mental status for any acute changes, anticipating
stressors, identifying new episodes early, and minimizing subsequent functional
impairments. A large body of evidence supports the efficacy of psychotherapy in the
treatment of unipolar depression. In bipolar depression, interpersonal therapy and
cognitive behavior therapy may be useful when added to pharmacotherapy.
Electroconvulsive Therapy (ECT) may also be considered for patients with severe or
treatment-resistant mania or if preferred by the patient in consultation with the physician.
In addition, ECT is a potential treatment for patients experiencing mixed episodes or for
patients experiencing severe mania during pregnancy.
Medications
Acute Treatment Phase

Severe Manic or Mixed Episodes -- The first-line pharmacological treatment for

more severe manic or mixed episodes is lithium plus an antipsychotic, or valproate
plus an antipsychotic. For less ill patients, monotherapy with lithium, valproate, or an
antipyschotic 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.
Atypical antipsychotics are prefered over typical
antipsychotics because of their more benign side effect profile.

Bipolar Depression -- The first-line treatment for bipolar depression is lithium or

lamotrigine. Antidepressant monotherapy is not recommended. Selective Seritonin
Reuptake Inhibitors (SSRIs) are believed to sometimes precipitate manic episodes.
Lithium with an antidepressant is an alternative to antidepressant monotherapy.

Rapid Cycling -- Rapid cycling refers to the occurrence of four or more mood
disturbances within a single year that meet criteria for a major depressive, mixed,
manic, or hypomanic episode. These episodes are demarcated either by partial or full
remission for at least 2 months or a switch to an episode of opposite polarity (e.g.,
from a major depressive to a manic episode). The initial intervention in patients who
experience rapid cycling is to identify and treat any medical conditions, such as
hypothyroidism or drug or alcohol use, that may contribute to cycling. Certain
medications, particularly antidepressants, may also contribute to cycling and should
be tapered or eliminated if possible. The initial treatment for patients who experience

Harvard Pilgrim/UBH
March 2009
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Clinical practice summaries are intended to guide treatment for patients with a specific behavioral health
disorder. This summary is not meant to substitute for individualized evaluation and treatment specific to
the members needs.

rapid cycling should include lithium or valproate; an alternative treatment is

lamotrigine. For many patients, combinations of medications are required.

Work-up -- When using lithium, valproic acid, or carbamazepine, careful monitoring

is necessary to ensure safe and effective dosing. A pregnancy test should be given
prior to initiation and then as clinically indicated. Each agent has serum plasma
concentration, complete blood count, blood chemistries, ECG, urinalysis, PT/PTT,
and thyroid function test baseline and routine monitoring protocols.

Following remission of an acute episode, patients may remain at particularly high risk of
relapse for a period of up to 6 months.
Maintenance Phase
Maintenance regimens of medication are recommended following a manic episode. The
medications with the best empirical evidence to support their use in maintenance
treatment include lithium and valproate; possible alternatives include lamotrigine,
carbamazepine or oxcarbazepine. If one of these medications was used to achieve
remission from the most recent depressive or manic episode, it generally should be
continued through the maintenance phase of treatment. Maintenance sessions of ECT
may also be considered for patients whose acute episode responded to ECT.
For patients treated with an antipsychotic medication during the preceding acute episode,
the need for ongoing antipsychotic treatment should be reassessed upon entering
maintenance treatment.
Psychotherapy
Persons with bipolar disorder are likely to benefit from a concomitant psychosocial
intervention including psychotherapy that addresses illness management including
medication adherence, lifestyle changes, interpersonal difficulties, and early detection of
symptoms. Group psychotherapy may also help patients address treatment plan
adherence, adaptation to 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.
RESOURCES
For further information, see the complete version of the American Psychiatric
Associations Practice Guideline for the Treatment of Patients with Bipolar Disorder,
available at www.psych.org. You can also call the UBH Physician Consultation Service
(1-800-292-2922) to discuss treatment concerns with a psychiatrist or contact UBH
Customer Service (1-888-777-4742) if you would like to make a referral to a mental
health professional.
Harvard Pilgrim/UBH
March 2009
3 of 3
Clinical practice summaries are intended to guide treatment for patients with a specific behavioral health
disorder. This summary is not meant to substitute for individualized evaluation and treatment specific to
the members needs.