Stop antidepressant (if taking)-
abruptly or gradually, depending on clinical need and risk of discontinuation/
withdrawal symptoms
Is patient already taking antimanic
medication ?
Consider
An antipsychotic (if symptoms severe or behaviour disturbed)
Managing episodes of mania and hypomania
No
Yes
The treatment of bipolar affective disorder
The treatment of bipolar can be divided into the following three categories:
-
Managing episodes of mania and hypomania
-
Managing depressive episodes
-
Long term management of bipolar disorder
Below are the management strategies for bipolar disorder according to the Maudsley prescribing guidelines accompanied by advice by NICE
Lithium
(if future adherence likely)
Valproate
(avoid in women of child-bearing potential)
If response is inadequate
Combine antipsychotic and valproate or lithium
All patients: consider adding short-term benzodiazepine
(lorazeam or clonazepam)
If taking an antipsychotic
Check compliance and dose. Increase dose if necessary. Consider adding lithium or valproate
If taking lithium
Check plasma levels. 1.0-1.2 mmol/l and/ or adding an antipsychotic
If taking valproate
Check plasma levels. Increase dose to give levels up to 125 mg/l if tolerated. Consider adding an antipsychotic
If taking lithium or valproate and mania is severe
Check plasma level
Add an antipsychotic
If taking carbamazepine
Consider adding an antipsychotic (higher doses may be needed)
All patients: consider adding short-term benzodiazepine
(lorazepam or clonazepam)
Advise all patients on:
– avoiding excessive stimulation – delaying important decisions
– calming activities – a structured routine with a lower activity level