For patients not already onLong-term treatment for bipolar disorder
Antidepressant monotherapy is not recommended
B
Consider treatment with an antidepressant (e.g. SSRI) together with an antimanic agent (e.g. lithium, valproate or an antipsychotic)
B
For mild to moderate depression consider initial treatment with lamotrigine, lithium or, possibly, valproate
B
Consider antipsychotics for patients with psychotic symptoms
A
For patients who have a depressive episode while on long-term treatment
Optimise dosing of existing medication and ensure that serum levels of lithium are within the therapeutic range
B
Consider adding, changing or augmenting antidepressant medication if depression is severe and optimisation has failed
A
Long-term treatment
Monotherapy options
Consider lithium as initial monotherapy
A
Carbamazepine is less effective than lithium; it may benefit patients who are intolerant of/poor responders to lithium and who do not show the classic pattern of episodic euphoric mania
B
Valproate may be more effective against depressive than against manic recurrences
B
Olanzapine may be more effective against manic than against depressive recurrences
B
Lamotrigine is more effective against depressive than against manic recurrences
B
In individual patients, good clinical response to any of the above agents may be considered evidence in favour of its long-term use as monotherapy
D
If monotherapy fails
Where mania predominates, consider combining mainly antimanic agents (e.g. lithium, valproate, an antipsychotic)
D
Where depression predominates, consider lamotrigine or an antidepressant in combination with an antimanic long-term agent
D
Consider clozapine in treatment-resistant patients
