Depending on which episode presents, getting patients to start treatment can be difficult. If patients are depressed, they are usually open to discussions about therapy to improve mood. On the other hand, hypomanic and manic patients are often extremely reluctant to accept the diagnosis, at least immediately, and it may take a while to establish the necessary trust with patients before they agree to treatment. For all three episodes - depression, mania or hypomania or mixed - a mood stabilizer is the foundation of treatment.

Mood stabilizers include lithium, divalproex (valproate), and carbamazepine; all are particularly helpful in mania and somewhat helpful in bipolar depressions. In bipolar patients with severe depression, an antidepressant may be required even though there is a risk of provoking rebound mania. If an antidepressant is required for greater symptom control in bipolar depression, the TCAs are more likely to induce mania and they should be avoided. Either bupropion or an SSRI is preferable because they are less likely to induce a mood switch, but the use of an antidepressant alone in bipolar depression without a mood stabilizer is not recommended. The antidepressant should be gradually discontinued, beginning 6 to 12 weeks after remission of depressive symptoms.

Patients should be aware that it may take up to two weeks before symptoms improve on a mood stabilizer. If they are experiencing significant sleep difficulties or agitation, a benzodiazepine may be introduced to neutralize these symptoms more quickly. Benzodiazepines can usually be taken for about one month without incurring the risk of dependence, and they should be gradually tapered once the mood stabilizer begins to work to offset potential withdrawal symptoms. Keep in mind, too, that it is better in the long run to start low and go slow, unless a patient is gravely ill. In some cases, antipsychotic medication may be needed.

Serum monitoring and subsequent dose titration is required with all three mood stabilizers; once therapeutic dosing is reached, approximately 70 % of patients respond well to the initial mood treatment strategy.

Treatment for Bipolar Affective Disorder: Suggested Starting Doses

Lithium: One 300 mg capsule at bedtime for 3 nights, double the dose to 600 mg to minimize side effects. Slow-release lithium is useful in patients with marked tremor or GI intolerance. Lithium or divalproex are recommended as first-line agents in patients with acute mania. Mixed state and rapid-cycling illness are less likely to respond to lithium. Lithium is also the treatment of choice in bipolar depression, and it is the drug of choice for the prophylactic treatment of bipolar disorder.

Carbamazepine: Start with 200 mg at bedtime for 3 nights, then double dose to 400 mg. Carbamazepine is a first-line agent in mixed mania.

Divalproex sodium (valproate): Start with 250 mg twice a day, and increase dose after one week. Divalproex is recommended as first-line in both acute mania and mixed bipolar illness and is the treatment of choice in rapid-cycling bipolar disorder. Divalproex sodium is associated with fewer GI side effects than valproic acid. Divalproex sodium is also more effective in rapid-cycling illness than lithium.

Gabapentin: Start at 300 mg/once a day, usually at bedtime. Every 3 to 5 days, the dose is increased, with some patients achieving a response with 600 mg/day; most often, the final dose is between 900 and 2,000 mg/day.

Lamotrigine: In patients not taking carbamazepine or valproate, lamotrigine is usually initially prescribed at a starting dose of 25 mg, once or twice a day, increasing the dose after 1 to 2 weeks by 25 to 50 mg, as needed and as tolerated. In patients taking valproate, the initial dose is often 12.5 mg/day, increasing the dose every 2 weeks by 12.5 or 25 mg/day. Larger initial doses of lamotrigine and more rapid increases in dose are possible in patients taking carbamazepine.

Electroconvulsive Therapy (ECT): For patients with severe behavioural disturbances induced by acute mania, the use of electroconvulsive therapy can lead to marked clinical improvement in some 80% of patients. Many manic patients also respond relatively rapidly to ECT when compared to the time it takes to achieve a therapeutic response with mood stabilizers, and patients who are refractory to pharmacotherapy often respond to ECT. Experts also agree that ECT is useful both in rapid-cycling and mixed state illness as well as in refractory states.

In depressions with a marked suicidal tendency or severe psychosis, ECT should also be considered early.