14th February 2025

Management of bipolar disorder

Management of acute mania or hypomania

NICE recommends an antipsychotic as first-line treatment of acute mania or hypomania: haloperidol, olanzapine, quetiapine or risperidone. Another of these can be trialled if the first is not effective or tolerated.

Second and third-line options are lithium and valproate respectively. If the patient already takes lithium, plasma levels should be taken to ensure they are within range.

For severe, treatment-resistant mania, electroconvulsive therapy (ECT) may be considered.

Management of bipolar depressive episodes

In bipolar depression, psychological interventions such as CBT should be offered. If the depressive episode is moderate or severe and the patient is not taking any medications, NICE recommends fluoxetine with olanzapine (as a mood stabiliser) or quetiapine (has antidepressant and mood-stabilising qualities).

Antidepressants should not be given alone in bipolar; a mood stabiliser is needed to reduce the risk of manic relapse.

Maintenance therapy for bipolar disorder

NICE advises that drugs effective in the acute phases of bipolar should be considered for long-term treatment. Antidepressants must not be given without a mood stabiliser.

Lithium is the most effective long-term treatment, and switching to it should be considered for all patients if not contraindicated. Valproate and olanzapine are second-line long-term mood stabilisers.

Structured psychological treatment such as individual, group or family therapy is also recommended.