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During the acute phase of any episode in bipolar disorder, regardless of whether it is mania or depression, the goals of treatment include:

• Stabilizing the episode
• Achieving remission
• Returning the patient to a baseline level of functioning with no symptoms

Though mania and depression are treated with the same medications, some of which have been approved by the U.S. Food and Drug Administration (FDA) for mania, to date there are no FDA approved drugs for the treatment of bipolar depression.

Mania

In 2002, the American Psychiatric Association (APA) issued a Practice Guideline for the treatment of bipolar disorder. In it they recommend that the following drugs be considered in combination for the first line of treatment for acute severe mania:

• Mood stabilizers (lithium and/or divalproex sodium)
• Antipsychotics (e.g., olanzapine)

For less severe episodes, any of these medications may be used as monotherapy (single drug therapies). During the manic episode, use of antidepressants is usually tapered and discontinued. Benzodiazapines are recommended in the short term if the patient is agitated. Lithium, divalproex and olanzapine are approved by the US Food and Drug Administration for treatment of mania.

The second-line of therapy for acute mania is either optimizing the first-line medications by raising their levels in the blood to therapeutic levels, adding medication to the first-line drugs, or switching to a different antipsychotic medication. Electroconvulsive therapy should remain an option for people with mixed mania episodes and pregnant women.

Lithium and divalproex are both effective for pure mania. Divalproex is also effective for mixed and rapid cycling and also has the advantage that it can be given initially in high doses for rapid relief.

Carbamazepine may be used in mixed and rapid cycling bipolar. It can be combined with lithium but not with divalproex. Carbamazepine may also be used if lithium and divalproex are contraindicated.

Newer anticonvulsants (e.g., lamotrigine, gabapentin, topiramate) may be used in combination with other first line drugs or as first line drugs if side effects of lithium and divalproex are intolerable.

Since mood stabilizers may take a few weeks to have an effect, they may be combined with other medications that provide short-term, rapid relief from anxiety, insomnia, and agitation in an acute episode. These include antipsychotics and benzodiazepine sedatives such as lorazepam (Ativan), clonazepam (Klonopin) and diazepam (Valium). The dosages of these medications can be reduced as the patient recovers.

Sometimes, patients experience a "breakthrough" episode that occurs when there is a manic or mixed episode recurrence despite receiving medications. Treatment consists of optimizing their medication and ensuring that blood levels of the drugs remain at a therapeutic level as determined by the physician.

To read more about the 2002 Practice Guidelines of the APA for treatment of bipolar disorder, please click on the following link:

http://www.psych.org/psychpract/treatg/pg/Bipolar2ePG05-15-06.pdf

In 2005, the American Psychiatric Association (APA) issued a Guideline Watch which summarizes significant developments in clinical practice since the last Practice Guidelines were published in 2002. Several medications are discussed in the Guideline Watch and are recommended by the APA to be considered as "options" for treatment of acute mania and mixed episodes (as monotherapy or adjunct therapy) including: