The most effective treatment of bipolar disorders is often a combination of psychotherapy and mood stabilizing medication.
The psychotherapeutic treatment is in many parts similar to the treatment of treatment of depressive disorders. However, during the manic phase most patients are only partially responsive to psychotherapeutic treatment. The therapy in the manic episodes may be difficult since during these episodes patients often lack the insight into the disease, and therefore there is often only a very low motivation for treatment.
The therapy in the manic episode is primarily supportive and structuring. Primary goal is to protect the patients. The structuring of the daily routine and the shielding from an excess of external influences as well as the regulation of the circadian rhythm can be felt supportive by the patients.
The pharmacotherapy of bipolar affective disorders is distinguished in the treatment of acute mania and in the recurrence prevention.
Treatment of acute mania
The International Society for Bipolar Disorders (ISBD) recommends lithium, valproate or atypical antipsychotic drugs as first choice in the treatment of acute mania (cf. Yatham 2009).
In the studies performed to date with regard to the atypical antipsychotics, there has been demonstrated an anti-manic effect of aripiprazole, olanzapine, quetiapine, risperidone, and ziprasidone. There is also evidence of an anti-manic effect for clozapine, however, the study data are still insufficient. As an alternative to the above mentioned monotherapy, there is recommended as a possible first-line therapy the combination treatment with lithium or valproate in combination with quetiapine, risperidone or olanzapine.
Relapse or recurrence prevention
The recommendations concerning the relapse and recurrence prevention include monotherapy with lithium, lamotrigine, valproic acid, quetiapine or olanzapine and the combination treatment with olanzapine + SSRI, Lithium + SSRI, Lithium + bupropion, valproic acid + SSRI or valproic acid + bupropion as a first choice (cf. Yatham 2009, Ansari 2010).
Regarding the bipolar disorders with “rapid-cycling” there is a presumption that the treatment with anticonvulsants is superior to lithium therapy.
There is evidence that the treatment with lithium or anticonvulsants can reduce the risk for suicide attempts in patients with bipolar affective disorder (cf. Gibbons 2009, Goodwin 2003, Greil 1997).
In bipolar disorders with severe depressive symptoms antidepressants may additionally be useful. However, the risk of a “switch effect” of some antidepressants has to be taken in consideration. “Switch effect” means that some antidepressants cause a shift from a depressive to a (hypo-)manic episode.