Management of Bipolar Disorder: Guidelines From the VA/DoD

Bipolar disorder has a lifetime prevalence of 1% in adults in the United States, and its onset peaks at three different ages—19, 26, and 29 years. The onset of bipolar disorder may be associated with asthma, migraines, multiple sclerosis, traumatic brain injury, and irritable bowel syndrome. More than 90% of patients with bipolar disorder report another mental health disorder, most commonly impulse control disorders, substance use disorders, and generalized anxiety disorder. The U.S. Department of Veterans Affairs and U.S. Department of Defense (VA/DoD) published new recommendations for diagnosing and managing bipolar disorder. These guidelines recommend management options when there is strong evidence of a benefit and suggest options when the evidence is not strong.

Routine screening for bipolar disorder is not suggested because of the high rates of false-positive results with most screening tools. Use of screening tools is suggested in specialty care when bipolar disorder is suspected; however, sensitivities can be less than 50% with limited specificity. Tools such as the Mood Disorder Questionnaire (https://ibpf.org/wp-content/uploads/2016/11/MDQ.pdf) are suggested for patients taking antidepressant medications who demonstrate signs of hypomania or mania. Scores have not been studied to guide care.

Pharmacotherapy should focus on treating patients in each phase of bipolar disorder—acute mania, acute depression, and maintenance therapy. Most medications have different effectiveness over the phases. Table 1 summarizes pharmacotherapy recommendations for each phase of bipolar disorder.