Bipolar Disorders: Evaluation and Treatment

 

Am Fam Physician. 2021 Feb 15;103(4):227-239.

  Patient information: A handout on this topic is available at https://familydoctor.org/condition/bipolar-disorder.

Author disclosure: No relevant financial affiliations.

Bipolar disorders are common, recurrent mental health conditions of variable severity that are difficult to diagnose. Affected individuals have higher rates of other mental health disorders, substance use disorders, and comorbid chronic medical illnesses. New diagnostic criteria and specifiers with attention on mixed features and anxious distress aid the physician in recognizing episode severity and prognosis. Physicians should consider bipolar disorder in any patient presenting with depression. Pharmacotherapy with mood stabilizers, such as lithium, anticonvulsants, and antipsychotics, is a first-line treatment that should be continued indefinitely because of the risk of patient relapse. Active lifestyle approaches include good nutrition, exercise, sleep hygiene, and proper weight management. Monotherapy with antidepressants is contraindicated during episodes with mixed features, manic episodes, and in bipolar I disorder. Ongoing management involves monitoring for suicidal ideation, substance use disorders, treatment adherence, and recognizing medical complications of pharmacotherapy. Psychotherapy is a useful adjunct to pharmacotherapy. Patients and their support systems should be educated about the chronic nature of this illness, possible relapse, suicidality, environmental triggers (e.g., seasonal light changes, shift work, other circadian disruption), and the effectiveness of early intervention to reduce complications.

Bipolar disorders comprise recurrent episodes of elevated mood and depression.1 The relapse rate is more than 70% over five years.2  Definitions of the various types of bipolar disorders are provided in Table 13,4 ; diagnostic criteria are listed in Table 2.3 Hypomania can occur in bipolar I and II disorders, whereas mania, which may include psychosis, appears only in bipolar I disorder. The nature and prognosis of the current episode and the likelihood of future ones can be described with specific attributes3  (Table 335).

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Screen all patients 12 years and older for depression, including all pregnant patients in the perinatal period; screening should be implemented with adequate systems in place to support accurate diagnosis, psychotherapy, and follow-up.24,25

B

Systematic review of randomized controlled clinical trials regarding treatment generalized to screening

Lithium, valproic acid (Depakote), and some antipsychotics are effective single agents for acute mania.12

A

Meta-analysis of randomized studies

Effective combination therapies for acute mania include lithium or valproic acid with quetiapine (Seroquel) or risperidone (Risperdal).12

A

Meta-analysis of randomized studies

Quetiapine and cariprazine (Vraylar) are effective single agents for the treatment of acute bipolar depression.12

A

Meta-analysis of randomized studies

Lurasidone (Latuda) combined with lithium or valproic acid is an effective treatment for acute bipolar depression.12

A

Meta-analysis of randomized studies

Lithium, quetiapine, or a combination of quetiapine and lithium or valproic acid is effective for maintenance of bipolar disorder.12

A

Meta-analysis of randomized studies


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Screen all patients 12 years and older for depression, including all pregnant patients in the perinatal period; screening should be implemented with adequate systems in place to support accurate diagnosis, psychotherapy, and follow-up.24,25

B

Systematic review of randomized controlled clinical trials regarding treatment generalized to screening

Lithium, valproic acid (Depakote), and some antipsychotics are effective single agents for acute mania.12

A

Meta-analysis of randomized studies

Effective combination therapies for acute mania include lithium or valproic acid with quetiapine (Seroquel) or risperidone (Risperdal).12

A

Meta-analysis of randomized studies

Quetiapine and cariprazine (Vraylar) are effective single agents for the treatment of acute bipolar depression.12

A

Meta-analysis of randomized studies

Lurasidone (Latuda) combined with lithium or valproic acid is an effective treatment for acute bipolar depression.12

A

Meta-analysis of randomized studies

Lithium, quetiapine, or a combination of quetiapine and lithium or valproic acid is effective for maintenance of bipolar disorder.12

A

Meta-analysis of randomized studies


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case

The Authors

show all author info

GABRIELLE MARZANI, MD, is assistant dean for admissions and an associate professor in the Department of Psychiatry and Neurobehavioral Sciences at the University of Virginia School of Medicine, Charlottesville....

AMY PRICE NEFF, MD, is a staff physician at Nashville (Tenn.) General Hospital and an outpatient community physician at Nashville Healthcare Center.

Address correspondence to Gabrielle Marzani, MD, University of Virginia School of Medicine, Claude Moore Medical Ed Building, 200 Jeanette Lancaster Way, Charlottesville, VA 22908 (email: grm2a@virginia.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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