Bipolar Disorder

The clinician managing bipolar disorder prescribes mood stabilizer regimens, manages treatment-resistant cases, navigates pregnancy planning, and coordinates long-term maintenance. The Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) guidelines provide evidence-based treatment algorithms. For acute mania: first-line monotherapy (lithium, valproic acid, quetiapine, risperidone, aripiprazole, paliperidone, asenapine, cariprazine); first-line combination (lithium or VPA + quetiapine, risperidone, aripiprazole, or asenapine). For bipolar depression: first-line (quetiapine, lurasidone + Li/VPA, lamotrigine, lithium, lurasidone monotherapy); adding an antidepressant is second-line and ONLY with mood stabilizer. For maintenance: lithium (strongest evidence for suicide prevention and long-term stabilization), quetiapine, lamotrigine (depression prevention), valproic acid (mania prevention in rapid cyclers). Treatment-resistant bipolar disorder may require: clozapine (most effective antipsychotic for refractory mania), ECT (effective for both acute mania and depression, safe in pregnancy), combination mood stabilizers (lithium + valproic acid + lamotrigine), or newer agents (cariprazine for bipolar depression). The clinician also manages the complex psychopharmacology of bipolar disorder in pregnancy: lithium (Ebstein anomaly 0.1-0.5%, requires fetal echo and third-trimester level monitoring), lamotrigine (safest mood stabilizer in pregnancy, but levels drop...