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For further details see Mental Health Prescribing Forum Prescribing Guideline PG13 Pharmacological Treatment of Bipolar Disorder
These guidelines cover three distinct therapeutic areas:
These guidelines only cover pharmacological management and other resources should be examined for appropriate psychological interventions in bipolar disorder, where they exist.
Healthcare professionals should fully involve individuals in decisions about their treatment and care, and determine treatment plans in collaboration with the individual, carefully considering the experience and outcome of previous treatment(s) together with individual preference.
Contraception and the risks of pregnancy (including the risks of relapse, damage to the foetus, and the risks associated with stopping or changing medication) should be discussed with all women of child-bearing potential, regardless of whether they are planning a pregnancy. They should be encouraged to discuss pregnancy plans with their doctor.
People experiencing a manic episode, or severe depressive symptoms, should normally be seen again within a week of their first assessment, and then regularly at appropriate intervals, for example, every 2–4 weeks in the first 3 months and less often after that, if response is good.
A key component to successful long term management of bipolar disorder is to engage the individual in recognising triggers or relapse signs e.g. insomnia. A Wellness Recovery Action Plan (WRAP) is an excellent tool for facilitating this work
If the individual is taking an antidepressant stop this as soon as safe to do so. Bear in mind withdrawal syndromes but this is often overridden by clinical need to halt the antidepressant quickly.
Antipsychotics are commonly used in acute episodes of mania but are also now licensed as mood stabilisers in their own right. This consideration is important when choosing an initial antipsychotic. Certain typical antipsychotics (e.g. haloperidol) are also licensed for acute mania but are not specifically included here due to their side effect profile.
See section 4.2 Drugs used in psychoses and related disorders.
When making the choice, prescribers should take into account preferences for future prophylactic use and the relevant side-effect profile.
Antipsychotic (see above)
For individuals who present with severe mania when already taking lithium or valproate, adding an antipsychotic should be considered at the same time as gradually increasing the dose of lithium or valproate. Already taking:
Treat as a hypomanic/manic episode and avoid prescribing antidepressants. Closer monitoring of suicidality is recommended, e.g. weekly follow up.
All episodes of depression where there is no history suggesting bipolar affective disorder should be treated in accordance with the Unipolar Depression guidance.
Antidepressants carry the risk of 'switching' to manic states when used in bipolar disorder, and they may be involved in cycle acceleration (mood destabilisation). When prescribing an antidepressant, an anti-manic agent should also be prescribed and specialist advice sought.
Ensure adequate doses of medicines and that serum levels of lithium are within the therapeutic range.
Ensure current choice of long-term treatments is likely to protect the patient from manic relapse (e.g. lithium, carbamazepine, valproate, antipsychotic).
A full therapeutic history is necessary to identify a treatment which is less associated with mood switching previously, or to identify an inadequate trial of treatment. Treatment trials should last 6 months, focus on optimising long-term treatments and not in response to individual episodes or symptoms.
Mania predominant (monotherapy or combinations): Lithium, Valproate, Olanzapine
Depression predominant: Quetiapine, Lamotrigine, Lithium, SSRIs with suitable antimanic prophylactic agent
Lithium has a narrow therapeutic range and monitoring is essential. Specialist services should provide the prescriber with target lithium concentrations and monitoring schedule.
Lithium monitoring is part of the Quality and Outcomes Framework (QOF).
Clinically appropriate monitoring which is accordance with the product licence should be undertaken and should include:
Drug interactions- see BNF
A DPT protocol on lithium is available: CP05 Prescribing and Monitoring of Lithium Therapy
The results of the biochemical tests should be to hand when prescribing lithium in accordance with the NPSA Patient Safety Alert Safer Lithium Therapy.
All individuals prescribed lithium must have a lithium treatment information pack (Purple book). This must be completed by the prescriber, including information about dose and relevant blood testing.
Prescribers are advised to seek specialist advice when a pregnancy is being planned. The National Teratology Information Service is available for NHS health professionals on 0844 892 0909 (8.30 – 17.00 Monday to Friday).
If an unplanned pregnancy occurs:
If a woman with bipolar disorder continues with an unplanned pregnancy, the newborn baby should have a full paediatric assessment, and social and medical help should be provided for the mother and child.
The use of valproate in pregnancy is contraindicated for bipolar disorder.
In April 2018 the MHRA issued a strengthened Drug Safety Update for valproate medicines which are now contraindicated in women and girls of childbearing potential unless conditions of Pregnancy Prevention Programme are met and only if other treatments are ineffective or not tolerated, as judged by an experienced specialist. All women and girls (and their parent, caregiver, or responsible person, if necessary) must be fully informed of the risks and the need to avoid exposure to valproate medicines in pregnancy.