Bipolar Disorder: Recognizing and Treating in Primary Care

MANAGEMENT

Management of bipolar disorder in the primary care setting includes psychiatric and psychologic counseling referrals. Primary care providers must know the medications used to treat bipolar disorder and their related adverse effects, toxicities, warnings, and drug interactions, as they may treat bipolar patients for other medical conditions. Early diagnosis and treatment/referral can improve prognosis and reduce the risk for relapse and subsequent disability.¹⁹ Inpatient management is generally recommended for severe manic episodes, psychotic episodes, patients who present a danger to themselves or others, and patients with suicidal or homicidal ideations/actions.

Medications are the primary treatment for all stages of bipolar disorder, and choice of medications is based on stage, previous response, and adverse effect profiles (see Table 1).^2,4,20 Generally, antidepressants (serotonin and norepinephrine reuptake inhibitors [SNRIs] and selective serotonin reuptake inhibitors [SSRIs]) should be avoided or should be used with an effective antimanic/mood stabilizer. Many patients with severe bipolar symptoms require more than two medications, and it is imperative that all primary care providers understand that often one drug alone is not sufficient treatment for patients with bipolar disorder. For less severe manic or hypomanic states, monotherapy with antipsychotics may be effective.

Medications for severe acute manic episodes generally include the mood stabilizers lithium, valproate, or carbamazepine in conjunction with an antipsychotic, such as haloperidol, or an atypical antipsychotic, such as asenapine, aripiprazole, olanza­pine, quetiapine, or risperidone.² The goal of initial therapy in patients with acute mania is rapid resolution of symptoms and restoration of adequate sleep. Lithium has a slower onset of action than valproate and carbamazepine and requires titration and monitoring. Valproate and carbamazepine have a faster onset of action but are less effective than lithium.² Atypical antipsychotics have a more rapid onset of action than mood stabilizers and are effective in controlling acute manic symptoms, psychosis, and sleep disturbances. Patients with severe acute mania may require hospital admission for stabilization, for their safety and the safety of others.

Acute bipolar depressive episodes can be treated with several different medication options, including combination olanzapine and fluoxetine; the atypical antipsychotic quetiapine; and recently lurasidone, alone or in combination with lithium or valproate. Lamotrigine is more effective for maintenance and prevention of depressive episodes than for treatment of acute episodes, and it is also indicated for treatment of bipolar II. Valproate is more effective than lithium for mixed states and can be titrated more rapidly for faster antimanic effects.⁴

Generally, due to the high rate of recurrence, maintenance medications should be continued indefinitely. Maintenance medications include the mood stabilizers, lamotrigine, and many of the antipsychotics, including olanzapine.⁴ Adherence to medications is essential in management of bipolar disorder and can decrease the risk for relapses and destabilization. Poor adherence to medications is common, however, with rates reported at approximately 50%.²¹ Patient and family education, as well as psychotherapy, can improve adherence rates.² Primary care providers should educate patients and family members about medication options and adverse effects and must stress the need for adherence to prevent relapse. Providers should also understand the safety profile of mood stabilizers and antipsychotics and the required monitoring of laboratory tests for patients on these medications.

Psychosocial treatments are an elemental component of management. Patients should be referred early for psychologic treatments including, but not limited to, family therapy, group therapy, cognitive-behavioral therapy, and psychotherapy, which have been shown to improve daily functioning, recognition of recurrences, and medication adherence.² The rate of relapse is significantly lower in patients receiving combination psychotherapy and pharmacotherapy.²²

Clinical pearls that every primary care provider should know about bipolar disorder are summarized in Table 2.

CONCLUSION

Given the substantial impact of bipolar disorder on patients and the community, primary care clinicians must maintain a high index of suspicion for this disorder. An early and accurate diagnosis may reduce the burden of bipolar disorder and improve outcomes. However, diagnosing and treating patients with bipolar disorder is challenging for primary care and specialty clinicians alike. In particular, establishing a diagnosis can be difficult, even for the most seasoned clinician, due to the diversity of symptoms. Nonetheless, diagnosing bipolar disorder, initiating treatment, and monitoring and referring patients when necessary are certainly within the purview of the primary care provider.