The pharmacological treatment of bipolar disorder in primary care

To provide a practical overview of the pharmacological management of adults with bipolar disorder in primary care and the role of general practitioners in the pharmacotherapy of this complex disorder.

Published guidelines for the treatment of bipolar disorder, plus Cochrane reviews, meta-analyses, review articles and reports from randomised controlled trials that were published up to May 2009.

Over 500 articles on the treatment of bipolar disorder were reviewed, with an emphasis on meta-analyses and systematic reviews of randomised controlled trials. Where evidence was more limited, open trials and non-controlled data were also reviewed.

Key recommendations relevant to GPs were synthesised and rated according to National Health and Medical Research Council levels of evidence.

Lithium, valproate and atypical antipsychotics are first-line treatment options for acute mania, and monotherapy is ideal if it produces an adequate response. For depressive episodes, recommendations are less definitive and the use of antidepressants is controversial. Most patients require maintenance treatment, during which pharmacotherapy should be used to prevent relapse, and psychological and social interventions should be considered.

Bipolar disorder is a lifelong episodic illness that affects 1%-2% of the population, many of whom are principally managed by their GPs. Pharmacological treatment with mood-stabilising agents is the primary form of management, although this is ideally provided in conjunction with psychosocial interventions.