Diagnosis & phase #
Bipolar I requires a manic episode: typically at least 7 days, or shorter when hospitalization is necessary. Bipolar II involves hypomania and major depression without a history of mania. Establish sustained changes in energy and activity as well as mood.
Document current phase, psychosis, mixed symptoms, episode recurrence and interepisode functioning. A depressed presentation can obscure past elevation; ask about consequences and collateral observations rather than only whether the person felt unusually happy.
In the DSM framework, hypomania lasts at least 4 consecutive days with an observable change in mood and activity; marked functional impairment, hospitalization or psychosis points to mania rather than hypomania. Do not equate brief stress-linked mood variation with a hypomanic episode.
Episode timeline & examination #
Create a timeline of mood, sleep, activity, spending, sexual behavior, substances and medicines. Establish prior antidepressant activation, admission, family history, treatment response and discontinuation. Check whether the person can maintain sleep, nutrition and cooperation with care.
Assess psychosis, agitation, impulsivity, self-harm and vulnerability. Review stimulants, corticosteroids, thyroid treatment and alcohol/drug exposure. New-onset late-life mania or abnormal neurological findings should broaden the medical assessment.
Distinguishing overlapping presentations #
| Presentation | Discriminator |
|---|---|
| ADHD | Developmental persistent pattern versus a distinct episode departing from baseline. |
| Personality-related affective instability | Context-linked changes versus sustained syndromal mood/energy change; conditions can coexist. |
| Substance or medication activation | Temporal relationship, exposure and persistence after the trigger. |
| Delirium or neurological illness | Attention, awareness, vital signs, focal findings and atypical course. |
Baseline tests & treatment readiness #
| Context | Assessment / tests | Clinical use |
|---|---|---|
| Before lithium | Weight/BMI, eGFR, electrolytes, calcium, thyroid function, full blood count; pregnancy assessment; ECG if cardiovascular risk | Identify contraindications, baseline abnormalities and monitoring needs. |
| Before an antipsychotic | Weight, blood pressure, glucose/HbA1c and lipids; movement examination and medicine-specific ECG considerations | Record baseline cardiometabolic and neurological burden. |
| Atypical onset or physical signs | Directed medical investigation rather than a routine indiscriminate panel | Identify endocrine, neurological or substance-related contributors. |
Phase-specific treatment #
View treatment map
- Acute mania
Consider an effective antipsychotic and/or lithium according to severity, prior response and monitoring feasibility. Severe behavioral disturbance may require inpatient treatment.
- Bipolar depression
Quetiapine is an established option. Lithium, lamotrigine and other bipolar-depression treatments require phase-specific guideline selection; do not substitute a unipolar depression algorithm.
- Mixed presentation
Reassess antidepressants and activating substances; treatment must address manic as well as depressive symptoms.
- Maintenance
Choose a regimen with recurrence-prevention evidence, matching predominant polarity, prior response, tolerability and reproductive considerations. Add psychoeducation and relapse planning.
| Phase | Clinical approach |
|---|---|
| Acute mania | Consider an effective antipsychotic and/or lithium according to severity, prior response and monitoring feasibility. Severe behavioral disturbance may require inpatient treatment. |
| Bipolar depression | Quetiapine is an established option. Lithium, lamotrigine and other bipolar-depression treatments require phase-specific guideline selection; do not substitute a unipolar depression algorithm. |
| Mixed presentation | Reassess antidepressants and activating substances; treatment must address manic as well as depressive symptoms. |
| Maintenance | Choose a regimen with recurrence-prevention evidence, matching predominant polarity, prior response, tolerability and reproductive considerations. Add psychoeducation and relapse planning. |
Doses & prescribing #
Each prescribing record identifies its population and source jurisdiction; international labeling does not establish Indian approval. The clinician selects treatment after assessment.
Quetiapine
Acute bipolar depression
Adults · Immediate-release tablets · Oral · United States product labeling
- Starting dose
- 50 mg at bedtime on day 1.
- Titration
- 100 mg day 2, 200 mg day 3, 300 mg day 4, if tolerated.
- Treatment range / target
- 300 mg at bedtime.
- Maximum / limits
- 300 mg/day for this labeled indication.
- Trial & duration
- Assess depressive symptoms and tolerability; maintenance is a separate phase decision.
- Monitoring
- Sedation, orthostasis, weight and metabolic changes.
- Population & organ-function adjustments
- Hepatic impairment: start 25 mg/day and titrate slowly. Older adults: slower individualized titration.
- Important cautions
- Review strong CYP3A4 interactions and fall risk.
Quetiapine
Acute bipolar I mania
Adults · Immediate-release tablets · Oral · United States product labeling
- Starting dose
- 50 mg twice daily on day 1.
- Titration
- Total daily doses 200, 300 and 400 mg on days 2–4; later increments ≤200 mg/day, up to 800 mg by day 6 if tolerated.
- Treatment range / target
- 400–800 mg/day in divided doses.
- Maximum / limits
- 800 mg/day.
- Trial & duration
- Acute stabilization; reassess continuation after recovery.
- Monitoring
- Orthostasis, sedation and metabolic parameters.
- Population & organ-function adjustments
- Hepatic impairment: 25 mg/day initially, slower increments; older/frail patients require slower titration.
- Important cautions
- Immediate-release schedule; do not apply to extended-release tablets.
Lithium
Bipolar I mania and maintenance: selected US capsule schedule
Adults · Lithium carbonate immediate-release capsules · Oral · United States product labeling
- Starting dose
- 300 mg three times daily in the cited adult label.
- Titration
- 300 mg increments every 3 days, guided by levels and clinical response.
- Treatment range / target
- Acute serum target 0.8–1.2 mEq/L; label maintenance target 0.8–1.0 mEq/L. These differ from NICE first-time maintenance targets below.
- Maximum / limits
- No single universal milligram ceiling: exposure, renal function and toxicity determine limits.
- Trial & duration
- Acute and maintenance use; long-term need reviewed separately.
- Monitoring
- Label: level after 3 days, sample 12 hours after last dose; repeat until stable and after relevant changes.
- Population & organ-function adjustments
- CrCl 30–89 mL/min: lower start and slower titration; CrCl <30: avoid.
- Important cautions
- Dehydration, sodium depletion, NSAIDs, diuretics and renin–angiotensin drugs can increase toxicity.
Reassess before escalation #
Confirm phase and adherence, distinguish persistent symptoms from adverse effects, and check relevant drug levels. Inadequate lithium exposure is different from failure despite adequate exposure. Persistent depressive symptoms also require reassessment for mixed features and substance use.
A specialist may optimize, switch or combine phase-appropriate treatments. Lamotrigine is not an acute antimanic drug. ECT is an option for severe or refractory episodes when a rapid or substantial response is needed; specialist assessment determines suitability.
Maintenance targets & discontinuation #
NICE recommends lithium 0.6–0.8 mmol/L for people starting lithium, with 0.8–1.0 mmol/L considered in selected relapse or residual-symptom situations. This guidance should not be silently merged with the different US label targets in the dose card.
Create a written early-warning plan for sleep, mood, activity and support contacts. When lithium is stopped, NICE recommends reduction over at least 4 weeks and preferably up to 3 months, with close observation for recurrence.
Special populations & reproductive context #
Pregnancy planning, contraception and breastfeeding need a medicine-specific specialist discussion. Valproate has major reproductive restrictions; an existing prescription must not be continued or newly selected without checking current applicable requirements.
Renal impairment, older age, interacting drugs and fluid loss change lithium handling. Intercurrent vomiting, diarrhea, fever or reduced intake warrants prompt clinical review; a previously acceptable dose can become toxic without any prescription change.
Monitoring schedule #
| Stage | Monitoring |
|---|---|
| Lithium initiation / dose change | SPS: level at 1 week, then weekly until stable; collect 12 hours after last dose. This is a UK monitoring schedule, distinct from the US initiation label. |
| Stable lithium treatment | Level every 3–6 months; weight/BMI, eGFR, electrolytes, calcium and thyroid function every 6 months. |
| Higher-risk lithium treatment | At least 3-monthly levels may be needed with interacting drugs, older age, renal/thyroid concerns, adherence changes or altered fluid/sodium intake. |
| Possible toxicity | Withhold lithium and obtain urgent clinical assessment, lithium level and electrolytes when toxicity is suspected; neurological symptoms matter even with a seemingly acceptable level. |
Clinical pitfalls #
Do not interpret sedation as resolution of mania or symptom reduction as restored judgment. Ask about actual behavior, sleep and the ability to function after discharge.
Avoid treating all phases with the same dose or assuming that efficacy in mania establishes efficacy in bipolar depression. Keep mood-switch monitoring active when antidepressants are used in a specialist treatment plan.
Assessment tools #
Choose the instrument for its intended purpose; interpretation accompanies the linked tool.
Patient discussion #
Open a plain-language explanation
The important pattern is change over time. A timeline and observations from someone trusted can help identify episodes that are difficult to recall.
Further reading #
References · 8
- NIMH — bipolar disorder and episode patterns · United States · Checked 2026-10-26 · Supports: Diagnosis & phase; Distinguishing overlapping presentations
- NICE CG185 — bipolar assessment, lithium and long-term management · United Kingdom · Checked 2026-10-26 · Supports: Episode timeline & examination; Baseline tests & treatment readiness; Maintenance targets & discontinuation
- CANMAT/ISBD — 2023 evidence update · Canada / international specialty guidance · Checked 2026-10-26 · Supports: Phase-specific treatment; Reassess before escalation; Special populations & reproductive context; Clinical pitfalls
- VA/DoD 2023 — bipolar disorder · United States · Checked 2026-10-26 · Supports: Episode timeline & examination; Distinguishing overlapping presentations; Phase-specific treatment; Reassess before escalation
- Quetiapine immediate-release tablets — product label, section 2 · United States · Checked 2026-10-26 · Supports: Quetiapine — Acute bipolar depression (Immediate-release tablets); Quetiapine — Acute bipolar I mania (Immediate-release tablets)
- Lithium carbonate capsules — product label, sections 2 and 8 · United States · Checked 2026-10-26 · Supports: Special populations & reproductive context; Lithium — Bipolar I mania and maintenance: selected US capsule schedule (Lithium carbonate immediate-release capsules)
- NHS SPS — lithium monitoring · United Kingdom · Checked 2026-10-26 · Supports: Baseline tests & treatment readiness; Monitoring schedule
- SAMHSA: DSM hypomania criteria comparison, Table 3.8 · United States; DSM framework · Checked 2026-10-26 · Supports: Diagnosis & phase