Management of Bipolar Disorder

Publication Date: September 30, 2023
Last Updated: October 12, 2023

Screening and Evaluation

We suggest against routine screening for bipolar disorder in a general medical population. (Weak against)
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In specialty mental health care, when there is suspicion for bipolar disorder from a clinical interaction, we suggest using a validated instrument (e.g., Bipolar Spectrum Diagnostic Scale, Hypomania Checklist, Mood Disorder Questionnaire) to support decision making about the diagnosis. (Weak for)
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For individuals with major depressive disorder being treated with antidepressants, when there is suspicion for mania/hypomania from a clinical interaction, we suggest using a validated instrument (e.g., Hypomania Checklist, Mood Disorder Questionnaire) as part of the evaluation for mania/hypomania. (Weak for)
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For individuals with bipolar disorder, there is insufficient evidence to recommend for or against any specific treatment outcome measures to guide measurement-based care. (Neither for or against)
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Pharmacotherapy

Acute Mania

We suggest lithium or quetiapine as monotherapy for acute mania. (Weak for)
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If lithium or quetiapine is not selected based on patient preference and characteristics, we suggest olanzapine, paliperidone, or risperidone as monotherapy for acute mania. (Weak for)
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If lithium, quetiapine, olanzapine, paliperidone, or risperidone is not selected based on patient preference and characteristics, we suggest aripiprazole, asenapine, carbamazepine, cariprazine, haloperidol, valproate, or ziprasidone as monotherapy for acute mania. (Weak for)
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We suggest lithium or valproate in combination with haloperidol, asenapine, quetiapine, olanzapine, or risperidone for acute mania symptoms in individuals who had an unsatisfactory response or a breakthrough episode on monotherapy. (Weak for)
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We suggest against brexpiprazole, topiramate, or lamotrigine as a monotherapy for acute mania. (Weak against)
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We suggest against the addition of aripiprazole, paliperidone, or ziprasidone after unsatisfactory response to lithium or valproate monotherapy for acute mania. (Weak against)
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There is insufficient evidence to recommend for or against other first-generation antipsychotics or second-generation antipsychotics, gabapentin, oxcarbazepine, or benzodiazepines as monotherapy or in combination for acute mania. (Neither for or against)
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Acute Bipolar Depression

We recommend quetiapine as monotherapy for acute bipolar depression. (Strong for)
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If quetiapine is not selected based on patient preference and characteristics, we suggest cariprazine, lumateperone, lurasidone, or olanzapine as monotherapy for acute bipolar depression. (Weak for)
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There is insufficient evidence to recommend for or against antidepressants or lamotrigine as monotherapy for acute bipolar depression. (Neither for or against)
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We suggest lamotrigine in combination with lithium or quetiapine for acute bipolar depression. (Weak for)
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There is insufficient evidence to recommend for or against ketamine or esketamine as either a monotherapy or an adjunctive therapy for acute bipolar depression. (Neither for or against)
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There is insufficient evidence to recommend for or against antidepressants to augment treatment with second-generation antipsychotics or mood stabilizers for acute bipolar depression. (Neither for or against)
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Prevention of Recurrence of Mania

We recommend lithium or quetiapine for the prevention of recurrence of mania. (Strong for)
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If lithium or quetiapine is not selected based on patient preference and characteristics, we suggest oral olanzapine, oral paliperidone, or risperidone long-acting injectable for the prevention of recurrence of mania. (Weak for)
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There is insufficient evidence to recommend for or against other first-generation antipsychotics, second-generation antipsychotics, and anticonvulsants (including valproate) for the prevention of recurrence of mania. (See Recommendations 18, 19, and 30). (Neither for or against)
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We suggest against lamotrigine as monotherapy for the prevention of recurrence of mania. (Weak against)
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We suggest aripiprazole, olanzapine, quetiapine, or ziprasidone in combination with lithium or valproate for the prevention of recurrence of mania. (Weak for)
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Prevention of Recurrence of Bipolar Depression

We recommend lamotrigine for the prevention of recurrence of bipolar depressive episodes. (Strong for)
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We suggest lithium or quetiapine as monotherapy for the prevention of recurrence of bipolar depressive episodes. (Weak for)
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If lithium or quetiapine is not selected based on patient preference and characteristics, we suggest olanzapine as monotherapy for the prevention of recurrence of bipolar depressive episodes. (Weak for)
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We suggest olanzapine, lurasidone, or quetiapine in combination with lithium or valproate for the prevention of recurrence of bipolar depressive episodes. (Weak for)
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There is insufficient evidence to recommend for or against other first-generation antipsychotics, other second-generation antipsychotics, and anticonvulsants (including valproate) as monotherapies for the prevention of recurrence of bipolar depressive episodes. (Neither for or against)
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There is insufficient evidence to recommend for or against other first-generation antipsychotics, other second-generation antipsychotics, and anticonvulsants in combination with a mood stabilizer for the prevention of recurrence of bipolar depressive episodes. (Neither for or against)
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Pregnancy/Childbearing Potential

For individuals with bipolar disorder who are or might become pregnant and are stabilized on lithium, we suggest continued treatment with lithium at the lowest effective dose in a framework that includes psychoeducation and shared decision making. (Weak for)
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We recommend against valproate, carbamazepine, or topiramate in the treatment of bipolar disorder in individuals of child-bearing potential. (Strong against)
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Other Somatic Therapies

For individuals with bipolar 1 disorder with acute severe manic symptoms, we suggest electroconvulsive therapy in combination with pharmacotherapy when there is a need for rapid control of symptoms. (Weak for)
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In individuals with bipolar 1 or bipolar 2 disorder, we suggest offering short-term light therapy as augmentation to pharmacotherapy for treatment of bipolar depression. (Weak for)
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For individuals with bipolar disorder who have demonstrated partial or no response to pharmacologic treatment for depressive symptoms, we suggest offering repetitive transcranial magnetic stimulation as an adjunctive treatment. (Weak for)
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Psychosocial and Recovery-Oriented Therapy

Psychotherapy

For individuals with bipolar 1 or bipolar 2 disorder who are not acutely manic, we suggest offering psychotherapy as an adjunct to pharmacotherapy, including cognitive behavioral therapy, family or conjoint therapy, interpersonal and social rhythm therapy, and non-brief psychoeducation (not ranked). (Weak for)
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For individuals with bipolar 1 or bipolar 2 disorder, there is insufficient evidence to recommend for or against any one specific psychotherapy among cognitive behavioral therapy, family or conjoint therapy, interpersonal and social rhythm therapy, and non-brief psychoeducation. (Neither for or against)
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Complementary and Integrative Health and Supplements

For individuals with bipolar 2 disorder, there is insufficient evidence to recommend for or against meditation as an adjunct to other effective treatments for depressive episodes or symptoms. (Neither for or against)
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In individuals with bipolar disorder, there is insufficient evidence to recommend for or against augmenting with nutritional supplements, including nutraceuticals, probiotics, and vitamins, for reduction of depressive or manic symptoms. (Neither for or against)
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Technology Based Care

For individuals with bipolar disorder, there is insufficient evidence to recommend for or against any particular phone application or computer- or web- based intervention. (Neither for or against)
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Supportive Care/Models of Care

Supportive Care

There is insufficient evidence to recommend any specific supported housing intervention over another for individuals with bipolar disorder experiencing housing insecurity. (Neither for or against)
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For individuals with bipolar disorder who require vocational or educational support, we suggest Individual Placement and Support or Individual Placement and Support Enhanced. (Weak for)
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Models of Care/Care Delivery

For individuals with bipolar disorder, we suggest caregiver support programs to improve mental health outcomes. (Weak for)
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For individuals with bipolar disorder, we suggest that clinical management should be based on the collaborative care model. (Weak for)
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Co-occurring Conditions

For individuals with bipolar 1 or bipolar 2 disorder and tobacco use disorder, we suggest offering varenicline for tobacco cessation, with monitoring for increased depression and suicidal behavior. (Weak for)
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For individuals with bipolar 1 or bipolar 2 disorder and cooccurring substance use disorder, there is insufficient evidence to recommend for or against any specific pharmacotherapy or psychotherapy intervention. See VA/DoD Clinical Practice Guideline for the Management of Substance Use Disorder. (Neither for or against)
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For individuals with fully or partially remitted bipolar disorder and with residual anxiety symptoms, we suggest cognitive behavioral therapy. (Weak for)
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Recommendation Grading

Disclaimer

The information in this patient summary should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.

Overview

Title

Management of Bipolar Disorder

Authoring Organization

Veterans Health Administration / Department of Defense

Publication Month/Year

September 30, 2023

Last Updated Month/Year

April 1, 2024

Document Type

Guideline

Country of Publication

US

Target Patient Population

The patient population of interest for this CPG is adults (age 18 years and older) treated with any diagnosis covered within “bipolar and related disorders” of the DSM-5-TR. It includes Veterans and Service members as well as their dependents.

Target Provider Population

This CPG is intended for use by VA and DoD primary care providers (PCP) and others involved in the health care team caring for individuals with BD.

Inclusion Criteria

Male, Female, Adult, Older adult

Health Care Settings

Ambulatory, Outpatient

Intended Users

Nurse, nurse practitioner, physician, physician assistant, psychologist

Scope

Counseling, Diagnosis, Assessment and screening, Treatment, Management

Diseases/Conditions (MeSH)

D001714 - Bipolar Disorder, D000068105 - Bipolar and Related Disorders

Keywords

bipolar, veteran, veterans, bipolar disorder

Methodology

Number of Source Documents
242
Literature Search Start Date
December 31, 2011
Literature Search End Date
December 30, 2021