Patient handout

Bipolar Disorder — acute mania + bipolar depression + maintenance (APA 2024; CANMAT/ISBD 2018; BALANCE Geddes Lancet 2010)

PRODUCTION

1. Your condition

This handout is for bipolar disorder — acute mania + bipolar depression + maintenance (apa 2024; canmat/isbd 2018; balance geddes lancet 2010). Your care team identified this based on: elevated/expansive/irritable mood + increased energy ≥1 week (mania) or ≥4 days (hypomania) (dsm-5-tr 2022 criterion a).

Other reasons your team may use this plan: major depressive episode in patient with prior mania or hypomania (dsm-5-tr 2022; apa 2024); manic or depressive episode with ≥3 features of opposite polarity (dsm-5-tr 2022 mixed-features specifier); grandiose or persecutory delusions, hallucinations during manic episode (dsm-5-tr 2022; apa 2024).

2. Your medications

Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.

Medication	Starting dose	How	When	What it does
lithium	300 mg PO TID; target level 0.8–1.2 mmol/L	PO	TID with level monitoring	First-line for acute mania — CANMAT/ISBD 2018 Level 1 evidence (Yatham); superior maintenance per BALANCE (Geddes Lancet 2010); anti-suicide benefit (Cipriani Lancet 2005)
valproate	500 mg PO BID or 20–30 mg/kg/day loading; target level 50–125 mcg/mL	PO	BID-TID with level monitoring	First-line for acute mania especially mixed or rapid cycling; contraindicated in pregnancy (FDA 2013 black-box; APA 2024; CANMAT/ISBD 2018 Yatham)

Plan: Acute mania pharmacotherapy — mood stabiliser + SGA (APA 2024; CANMAT/ISBD 2018 Yatham)

3. Your action plan

Use these zones to know what to do based on how you feel.

GREEN — Doing well — euthymic, stable sleep, adherent to medication (APA 2024)

If you have:

Mood stable and consistent (APA 2024)
Sleeping 7–9 h on regular schedule (Harvey Sleep Med Rev 2008; APA 2024)
Engaging with usual activities, work, relationships (APA 2024)
Taking mood stabiliser as prescribed, levels at target (APA 2024)
No suicidal thoughts (C-SSRS; Posner 2011)

Do this:

Take mood stabiliser every day at the same time — NEVER stop or change dose without provider (APA 2024; BALANCE Geddes Lancet 2010)
Keep consistent sleep-wake schedule — sleep deprivation is a mania trigger (Harvey Sleep Med Rev 2008; APA 2024)
Avoid alcohol, recreational drugs, and stimulants (APA 2024; CANMAT/ISBD 2018)
Keep follow-up appointments and lab monitoring on schedule (APA 2024)
Practice social rhythm therapy techniques (Frank Int J Bipolar Disord 2015)
Keep crisis plan and contact numbers accessible (APA 2024; NICE 2024)

YELLOW — Caution — early warning signs of mood shift (mania or depression) (APA 2024; NICE 2024)

If you have:

Sleeping <6 h and not feeling tired, OR sleeping >10 h (Harvey Sleep Med Rev 2008; APA 2024)
Talking faster than usual, racing thoughts, increased goal-directed activity (DSM-5-TR 2022)
Spending more money, increased risky behaviour, irritability (DSM-5-TR 2022; APA 2024)
Low mood, loss of interest, social withdrawal, hopelessness (DSM-5-TR 2022)
Missed medication doses (APA 2024)
Increased alcohol or substance use (APA 2024; CANMAT/ISBD 2018)

Do this:

Use your personal early warning sign list and crisis plan immediately (NICE 2024; APA 2024)
Prioritise sleep — dark room, no screens, consider short-term PRN if prescribed (APA 2024)
Contact your psychiatrist or care team for early review — within 48–72 h (APA 2024)
Check medication adherence — resume if missed; do NOT double dose (APA 2024)
Avoid major decisions, spending, new commitments until reviewed (APA 2024)
Tell a trusted person what you are noticing (NICE 2024; Miklowitz JAMA Psych 2007)

Call your provider if:

Any warning signs persist >48 h despite self-management (APA 2024)
Sleep <4 h × 2 consecutive nights (Harvey Sleep Med Rev 2008; APA 2024)
Feeling out of control with spending, speech, or activity (APA 2024)
Return of suicidal thoughts (APA 2024)
Missed >2 doses of mood stabiliser (APA 2024)

RED — Medical alert — active mania/psychosis, active SI, lithium toxicity, NMS (APA 2024)

If you have:

Not sleeping at all for ≥2 nights (APA 2024)
Hearing voices, paranoia, grandiose beliefs that are not reality-based (DSM-5-TR 2022; APA 2024)
Specific plans to harm yourself or others (C-SSRS; Posner 2011; APA 2024)
Severe shaking, confusion, slurred speech, vomiting while on lithium — possible toxicity (APA 2024)
High fever + rigid muscles + confusion on antipsychotic — possible NMS (Caroff Expert Opin Drug Saf 2015)
Reckless behaviour putting yourself or others at physical risk (APA 2024)

Do this:

Call 988 (US) / your local crisis line / emergency services NOW (APA 2024)
Go to the nearest emergency department; do not drive yourself if confused or impaired (APA 2024)
If lithium toxicity suspected — stop lithium, hydrate, go to ED (APA 2024)
Hand firearms, excess medications, car keys to a trusted person (VA/DoD 2022; APA 2024)
Activate your advance directive / crisis plan (NICE 2024; APA 2024)

Call your provider if:

Any red zone trigger — emergency department immediately (APA 2024)

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

YMRS ≥30 — severe acute mania requiring combination pharmacotherapy and likely inpatient admission (Young 1978; APA 2024)
C-SSRS positive for active SI with intent, plan, or recent preparatory behaviour in bipolar patient (Posner 2011; APA 2024)(life-threatening)
Psychotic features during mania — grandiose/persecutory delusions, hallucinations (DSM-5-TR 2022)
Catatonic features — motor immobility, mutism, negativism, posturing ≥2 signs on Bush-Francis screen (APA 2024; Fink 2013)
Lithium level >1.5 mmol/L or symptoms (coarse tremor, ataxia, confusion, vomiting) at any level (APA 2024)(life-threatening)
Neuroleptic malignant syndrome — rigidity, hyperthermia >38 C, AMS, autonomic instability, CK >1000 on antipsychotic (Caroff Expert Opin Drug Saf 2015)(life-threatening)
Positive pregnancy test in patient on valproate — neural tube defect risk 1–2% (FDA 2013 black-box; APA 2024)
Manic or depressive episode with ≥3 features of opposite polarity (DSM-5-TR 2022 mixed-features specifier) AND any C-SSRS-positive ideation — mixed states carry the highest SI risk in bipolar (Pompili 2013 PMID 23755739; APA 2024)
≥4 mood episodes in 12 months (DSM-5-TR 2022 rapid-cycling specifier) — emerging or established (CANMAT/ISBD 2018 Yatham PMID 29536616)

5. Follow-up

Lifelong maintenance recommended for BP I after single manic episode (APA 2024; BALANCE Geddes Lancet 2010); lithium preferred — 30% relapse reduction vs valproate alone (BALANCE Geddes Lancet 2010); psychoeducation + sleep hygiene + circadian rhythm stabilisation (Frank Int J Bipolar Disord 2015); relapse prevention CBT/IPSRT reduces relapse (Miklowitz JAMA Psych 2007); lifestyle (exercise, alcohol avoidance, social rhythm) (APA 2024; NICE 2024)

6. Sources

Guideline: APA Practice Guideline for Bipolar Disorder 2024 + CANMAT/ISBD 2018 (Yatham Bipolar Disord) + NICE CG185 2024 update