RAPID CYCLING BIPOLAR DISORDER (see algorithm)

Rapid cycling bipolar disorder may be a phase of the disorder or, in some cases, a type of disorder. It is important to stabilize sleep, reduce or stop the use of caffeine, nicotine, alcohol and substances. Antidepressant medications, particularly tricyclics, may provoke rapid cycling. Care should be taken to gradually discontinue and not to abruptly discontinue any psychotropic agent.

Divalproex sodium is the first treatment of choice. In partial or non-responders, Lithium or Carbamazepine may be added to the Divalproex. Further on, the combination of three mood stabilizers or ECT could be tried. Lamotrigine, Gabapentin, Nimodipine or Thyroxine in addition to an established mood stabilizer may be used. Clozapine should be considered in the truly refractory patient.