Most patients with mania will require short-term medication and admission to hospital, the aim being to reduce the severity and shorten the duration of the acute episode. Patients should stop taking any substances known to cause mania when an episode begins. This includes medicines such as antidepressants, cold remedies and decongestants, and stimulants such as illegal drugs and caffeine.

For an acute episode, antipsychotics such as haloperidol, olanzapine, quetiapine and risperidone are most effective in the short-term reduction of manic symptoms and most likely to be used. Lithium, valproate or aripiprazole can be used if antipsychotics are ineffective. Lithium is rarely used in mania due to the risk of toxicity. Benzodiazepines may also be used short-term to promote sleep for agitated overactive patients.

Management of the acute depressive episode

Antidepressants have not been adequately studied in bipolar depression and they can induce mania in some patients. So far only the combination of fluoxetine with olanzapine has been shown to be effective in treating bipolar depression. Despite this, antidepressants are commonly prescribed in bipolar disorder but should always be co-prescribed with an antipsychotic, lithium or valproate in patients with a history of mania.

Treatments of bipolar depression include quetiapine, lurasidone (unlicensed), olanzapine (without fluoxetine) or lamotrigine. If lamotrigine is prescribed it is often combined with an antipsychotic, lithium or valproate to protect against mania.

Patients with bipolar depression currently taking lithium, valproate or antipsychotics should have doses and plasma levels checked to ensure they are within the usual target range. If this treatment is still not effective, quetiapine, olanzapine (with or without fluoxetine) or lamotrigine can be added as concomitant therapy.

Long-term treatment: lithium

Lithium is the most effective long-term treatment for bipolar disorder – it is associated with a reduced risk of suicide and is the treatment of choice for most patients – but is not recommended for patients with poor adherence as rapid discontinuation may increase the risk of relapse. When lithium is ineffective, poorly tolerated or in patients unlikely to be adherent, valproate or an antipsychotic may be prescribed instead.

Patients primarily affected by mania should be treated with the predominantly antimanic medicines lithium, olanzapine, quetiapine, risperidone long-acting injection or valproate. Those primarily affected by depressive episodes should be prescribed lithium, lamotrigine or quetiapine.

Lithium modifies the production and turnover of neurotransmitters, particularly serotonin and may also block dopamine receptors. Patients receiving lithium must be monitored closely and plasma levels should be between 0.4 and 1.0mmol per litre (levels above 1.0mmol/l should always be queried). Levels will usually be monitored every three months (and monthly when levels are between 0.8 and 1.0mmol/l). If the current blood level is above the target range and the patient has symptoms of toxicity, he/she should be immediately referred to their doctor or to A&E.

With side effects affecting the kidneys and the thyroid gland, renal and thyroid function need to be assessed prior to starting lithium and repeated every six months during treatment. Patients on lithium should have a record booklet, which prescribers and pharmacists should use to check that blood tests are monitored regularly and that it is safe to issue a repeat prescription and/or dispense the prescribed lithium. There is also a patient information booklet available which contains important patient information that a patient can refer to for advice of side effects.

Discontinuation