Bipolar Disorder: A Primary-Care Playbook (diagnosis, mania care, and depression management)
- Diagnosis & decision-making in primary care
Screen for bipolar whenever depression is on the table. Ask about past periods of elevated/irritable mood, decreased need for sleep, impulsivity, family history, and antidepressant-induced activation. The Mood Disorder Questionnaire (MDQ) is a quick screen that helps flag risk while you take a full history.
Rule out mimics & contributors: substance use, thyroid disease, sleep disorders, medications/stimulants, and medical/neurologic causes. If bipolar is plausible, avoid antidepressant monotherapy and consider mood-stabilizing strategies or urgent specialty input.
When to refer/urgent steps: psychosis, suicidality, severe functional decline, or unclear diagnosis despite screening—initiate safety planning and coordinate rapid psychiatry/hospitalization pathways. Primary-care-focused algorithms outline stepwise confirmation and initial management while you arrange specialty care.
- Mania—diagnosis & treatment recommendations
First-line acute treatment: lithium, valproate, or a second-generation antipsychotic (e.g., quetiapine, risperidone, olanzapine; selection guided by comorbidity, prior response, and side-effect profile). Hospitalize if safety, impaired judgment, or poor support makes outpatient care risky.
Practice details from major guidelines (NICE/CANMAT): ensure a full tear-off of contributing meds (stop antidepressants), start an antimanic agent, add short-term benzodiazepine if needed for agitation/insomnia, and address psychoeducation and sleep–wake regularity early. Ongoing care includes relapse prevention, metabolic and lab monitoring (e.g., lithium levels, renal/thyroid; valproate LFTs/platelets).
- Clinical depression management (in bipolar disorder)
Do not use antidepressant monotherapy in suspected/confirmed bipolar depression due to switch risk; if used at all, it should be adjunctive under specialist oversight.
Evidence-supported options: quetiapine monotherapy; lurasidone adjunctive to lithium/valproate (or as monotherapy in some guidance); lithium or lamotrigine (often for prevention/relapse reduction, sometimes adjunctive in acute episodes); and olanzapine-fluoxetine combination or cariprazine where available/appropriate. Selection is guided by symptoms (e.g., anxiety, hypersomnia), prior response, and tolerability.
Psychotherapy & somatic treatments: combine medication with CBT/psychoeducation/IPSRT (sleep–rhythm focus). ECT remains a highly effective option for severe, psychotic, or treatment-refractory bipolar depression.
- A quick primary-care algorithm
Depressed patient? Screen for bipolar features (MDQ + history). If positive/uncertain, treat as possible bipolar and avoid SSRI/SNRI monotherapy.
If manic/mixed features now: start lithium/valproate or an SGA, ensure sleep, manage risks, expedite psychiatry.
If bipolar depression: consider quetiapine, lurasidone (+/- lithium/valproate), or lamotrigine strategies; add structured psychotherapy; monitor closely (PHQ-9 or QIDS every 2–4 weeks).
Maintenance: continue the effective regimen; address lifestyle, substances, and adherence; schedule labs and metabolic checks per agent.
- Monitoring & practical safety
Lithium: serum levels, creatinine/eGFR, thyroid; counsel on hydration/drug interactions.
Valproate/carbamazepine: LFTs, CBC; watch teratogenic risks.
Antipsychotics: weight, lipids, glucose, EPS/akathisia; consider ECG if QTc risk. (Monitoring frameworks are embedded in CANMAT/NICE guidance.)
Takeaway: In primary care, think “screen early, stabilize first, personalize later.” Use the MDQ and history to catch bipolar patterns, treat mania promptly with lithium/valproate/SGAs, and manage bipolar depression with guideline-supported options (not antidepressant monotherapy). Coordinate closely with psychiatry and keep a firm eye on labs, safety, and relapse prevention.
Educational only—if you or someone you’re helping is in crisis (suicidal thoughts, psychosis), seek emergency care immediately.