The treatment of bipolar disorder includes:

• Management of acute manic episodes
• Management of the acute depressive episodes
• Long-term treatment. 

Acute manic episode

Most patients with mania will require short-term medication to reduce the severity and duration of the acute episode. Patients should stop taking any substances known to cause mania when an episode begins. 

The antipsychotics haloperidol, olanzapine, quetiapine and risperidone are most effective in the short-term reduction of manic symptoms. Lithium, valproate or aripiprazole can be used if antipsychotics are ineffective. Benzodiazepines may also be used short-term to promote sleep for agitated overactive patients.

Patients who experience a manic or hypomanic episode while taking medication should have their dose adjusted. If symptoms are inadequately controlled with optimal doses, or the mania is very severe, another medicine is often prescribed.

Acute depressive episode

Bipolar depression can be treated with psychological interventions such as family focused therapy (FFT), cognitive behavioural therapy (CBT) or interpersonal and social rhythm therapy (IPSRT). This can include monitoring for signs of mania or hypomania and deterioration of the depressive symptoms. CBT therapy can be used alone, whereas the other psychological therapies should be used alongside medication. 

Antidepressants have not been adequately studied in bipolar depression and they can induce mania in some patients. Only the combination of fluoxetine with olanzapine has shown effectiveness in treating bipolar depression. 

Other treatments of bipolar depression include quetiapine, lurasidone, 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 taking lithium, valproate or antipsychotics should have their doses and plasma levels checked to see if they are within the usual target. If this treatment is still not effective, quetiapine, olanzapine (with or without fluoxetine) or lamotrigine can be added as concomitant therapy.