Evidence Based Guidelines Bipolar Disorder Treatment

Evidence Based Guidelines for

Bipolar Disorder Treatment: 

Revised Third Edition Recommendations From the British Association for Psychopharmacology



(1) Patient NOT on Long Term Treatment:


  • Haloperidol, Olanzapine, Risperidone & Quetiapine (effective in short term reduction of symptoms).
  • Valproate: alternative treatment option (but use with caution in women of child bearing age)
  • In Agitated Patient: Dopamine antagonists/partial agonists and GABA modulators (benzodiazepines)- in lowest doses necessary.
  • Antidepressants should be tapered and discontinued.
(2) Patient ON Long Term Treatment:


  • Consider highest tolerated dose of current medication.
  • For Lithium: 0.8-1 nmol/L may be more effective.
  • With Lithium: Consider adding dopamine antagonist or partial agonist, or valproate.
  • Consider Clozapine in more refractory cases.
  • ECT may be considered for: severe treatment resistance, patient preference and severe mania during pregnancy.



(1) Patient NOT on Long Term Treatment:

    • Quetiapine, Lurasidone or Olanzapine.


    • Antidepressants not adequately studies: Only Fluoxetine + Olanzapine has support.


    • Consider Lamotrigine (usually as an addition to agents preventing recurrence of mania).


    • Consider ECT: high suicidal risk, treatment resistance, psychosis, severe depression during pregnancy or life-threatening condition.


  • Consider family-focused, cognitive behaviour therapy or interpersonal rhythm therapy as an additional treatment.

(2) Patient ON Long Term Treatment:

  • Consider highest tolerated dose of current medication.

(3) Note on Antidepressants:

    • Antidepressant are unlikely to induce mania when used in combination with a drug for mania.


    • Consider Discontinuation of antidepressants after as little as 12 weeks in remission.


  • Longer treatment with antidepressants is justified if patients relapse on their withdrawal.



  • Offer enhanced psychoeducation, motivational and family support, especially in the early stages of illness to promote behavior change and adherence to medication.
  • Preferred strategy is for continuous rather than intermittent treatment with medications.

(1) Choice of Long Term Medications:


  • Lithium> Valproate> Olanzapine > Lamotrigine> Quetiapine> Carbamazepine.
  • Consider lithium as initial monotherapy
  • Lamotrigine and quetiapine may be considered as monotherapy in bipolar II disorder.
(2) If Patient Fails to Respond to Monotherapy and Continues to Experience Subthreshold Depressive Symptoms or Relapses:


  • In mania: combine two predominantly anti-manic agents (e.g. lithium, valproate, dopamine antagonist or a dopamine partial agonist)
  • In bipolar depression: Combination of lithium, lamotrigine, quetiapine, lurasidone or olanzapine may be more appropriate.
  • Consider continuation of clozapine if effective in refractory mania.
  • Maintenance ECT may be considered for patients who respond to ECT during an acute episode but respond poorly to all oral agents.
  • Consider adjunctive psychotherapy to address subthreshold symptoms
 (3) Discontinuation of Long Term Medications:


  • Following Discontinuation the risk of relapse remains, even after years of sustained remission.
  • Medications should normally be tapered over at least 4 weeks and preferably longer.
  • Early relapse to mania is an early risk of abrupt lithium discontinuation.



 (1) For Mania:

    • Consider Aripiprazole as first line.


  • Some evidence that olanzapine, quetiapine, and risperidone are efficacious in adolescents.

(2) For Bipolar Depression:


  • Same recommendations as adults above.


SourceJournal of Psychopharmacology 2016, Vol. 30(6) 495–553


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Dr. Harvinder Singh, M.D. (Admin)

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