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psych.bipolar-disorder.core.v1PRODUCTION
psych.bipolar-disorder.core.v1

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

psychiatryacutechronicadult
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Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Confirm DSM-5-TR 2022 bipolar I or II diagnosis — at least one manic (BP I) or hypomanic (BP II) episode; identify current episode polarity (manic, depressive, mixed, or euthymic maintenance) (APA 2024)

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Bipolar diagnosis confirmed with polarity and subtype specified (DSM-5-TR 2022; APA 2024)

Patient inputs (19)

Drug selection and dose adjustment; adolescent vs adult vs geriatric (APA 2024; CANMAT/ISBD 2018 Yatham)

Valproate contraindicated in pregnancy (FDA 2013 black-box); lithium Ebstein risk low but requires shared decision-making (APA 2024; CANMAT/ISBD 2018)

Number, polarity, and timing of prior episodes — determines BP I vs BP II, rapid cycling (DSM-5-TR 2022; APA 2024)

Prior lithium / valproate / lamotrigine / SGA response guides re-selection (APA 2024; CANMAT/ISBD 2018 Yatham)

Comorbid SUD in >40% of bipolar — worsens course, affects drug choice (APA 2024; CANMAT/ISBD 2018)

Renal disease affects lithium; hepatic disease affects valproate; metabolic syndrome affects SGA choice (APA 2024; CANMAT/ISBD 2018 Yatham)

Identify current mood stabilisers, antidepressants (discontinue if manic switch), CYP interactions, QTc load (APA 2024)

Baseline renal function for lithium; electrolytes for safety (APA 2024; CANMAT/ISBD 2018)

Hypothyroidism from lithium; thyroid dysfunction mimics mood episodes (APA 2024)

Baseline for valproate (thrombocytopenia) and carbamazepine (agranulocytosis) (APA 2024; CANMAT/ISBD 2018)

Hepatotoxicity monitoring for valproate (APA 2024; CANMAT/ISBD 2018 Yatham)

Valproate absolute contraindication in pregnancy (FDA 2013 black-box); lithium shared decision-making (APA 2024)

C-SSRS — bipolar carries 20–30× population suicide risk (Pompili Bipolar Disord 2013; APA 2024)

Young Mania Rating Scale stratifies acute mania severity and tracks response (YMRS Young 1978; APA 2024)

Metabolic baseline before SGA initiation — APA/ADA 2004 consensus; CANMAT/ISBD 2018

QTc baseline before SGA especially ziprasidone (FDA; APA 2024); lithium T-wave changes (APA 2024)

Therapeutic drug monitoring — acute mania 0.8–1.2 mmol/L, maintenance 0.6–0.8 mmol/L (APA 2024; BALANCE Geddes Lancet 2010)

Therapeutic 50–125 mcg/mL for acute mania (APA 2024; CANMAT/ISBD 2018)

PHQ-9 or MADRS stratifies bipolar depression severity (APA 2024; CANMAT/ISBD 2018 Yatham)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (9)

9 need judgement
  • informationallife_threateningactive_si_bipolar (C-SSRS; Pompili Bipolar Disord 2013; APA 2024)
    C-SSRS positive for active SI with intent, plan, or recent preparatory behaviour in bipolar patient (Posner 2011; APA 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateninglithium_toxicity (APA 2024)
    Lithium level >1.5 mmol/L or symptoms (coarse tremor, ataxia, confusion, vomiting) at any level (APA 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningnms_on_antipsychotic (Caroff Expert Opin Drug Saf 2015; APA 2024)
    Neuroleptic malignant syndrome — rigidity, hyperthermia >38 C, AMS, autonomic instability, CK >1000 on antipsychotic (Caroff Expert Opin Drug Saf 2015)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresevere_mania_ymrs_30 (Young 1978; APA 2024)
    YMRS ≥30 — severe acute mania requiring combination pharmacotherapy and likely inpatient admission (Young 1978; APA 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepsychotic_features_in_mania (DSM-5-TR 2022; APA 2024)
    Psychotic features during mania — grandiose/persecutory delusions, hallucinations (DSM-5-TR 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverecatatonia_in_bipolar (Bush-Francis; APA 2024)
    Catatonic features — motor immobility, mutism, negativism, posturing ≥2 signs on Bush-Francis screen (APA 2024; Fink 2013)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepregnancy_on_valproate (FDA 2013; APA 2024)
    Positive pregnancy test in patient on valproate — neural tube defect risk 1–2% (FDA 2013 black-box; APA 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveremixed_features_with_si (DSM-5-TR 2022; Pompili Bipolar Disord 2013; 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)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevererapid_cycling_emergence (DSM-5-TR 2022 rapid-cycling specifier; STEP-BD Sachs NEJM 2007; CANMAT/ISBD 2018 Yatham)
    ≥4 mood episodes in 12 months (DSM-5-TR 2022 rapid-cycling specifier) — emerging or established (CANMAT/ISBD 2018 Yatham PMID 29536616)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

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RISK_STRATIFICATIONoptionalDrives severity classification
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Recommended regimen

Acute mania pharmacotherapy — mood stabiliser + SGA (APA 2024; CANMAT/ISBD 2018 Yatham)
axis: bipolar_acute_maniastep 1 - Step 1 — Lithium or valproate monotherapy for mild-moderate mania (APA 2024; CANMAT/ISBD 2018)
Selected step "Step 1 — Lithium or valproate monotherapy for mild-moderate mania (APA 2024; CANMAT/ISBD 2018)" — YMRS <30, no psychotic features, no severe agitation (APA 2024)
  • lithium
    first line
    mood_stabiliser
    300 mg PO TID; target level 0.8–1.2 mmol/L • PO • TID with level monitoring (max: 1800 mg/day (level-guided))
    triggers: acute_mania, prior_lithium_response
    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)
    rxcui 6448
  • valproate
    first line
    mood_stabiliser
    500 mg PO BID or 20–30 mg/kg/day loading; target level 50–125 mcg/mL • PO • BID-TID with level monitoring (max: 60 mg/kg/day (level-guided))
    triggers: acute_mania, mixed_features, rapid_cycling
    First-line for acute mania especially mixed or rapid cycling; contraindicated in pregnancy (FDA 2013 black-box; APA 2024; CANMAT/ISBD 2018 Yatham)
    rxcui 11118

outpatient playbook — drug actions (4)

  1. 1. lithium maintenance
    300 mg BID–TID; target 0.6–0.8 mmol/L • PO • BID-TID with q3–6 mo levels
    trigger: First-line maintenance for BP I (APA 2024; BALANCE Geddes Lancet 2010)
    BALANCE (Geddes Lancet 2010): lithium superior to valproate; anti-suicide (Cipriani Lancet 2005); lifelong recommended for BP I (APA 2024)
  2. 2. lamotrigine for depression-predominant BP II maintenance
    200 mg PO daily (slow titrate if starting) • PO • daily
    trigger: BP II with depressive predominant polarity (APA 2024; CANMAT/ISBD 2018 Yatham)
    Better at preventing depressive relapse; slow titration — SJS risk (Calabrese JCP 2003; APA 2024)
  3. 3. SGA maintenance adjunct
    Aripiprazole 10–15 mg or quetiapine 300–400 mg or aripiprazole LAI 400 mg monthly • PO/IM • daily or monthly (LAI)
    trigger: Breakthrough on mood stabiliser monotherapy (APA 2024; CANMAT/ISBD 2018)
    SGA augmentation for incomplete maintenance response (APA 2024; CANMAT/ISBD 2018 Yatham)
  4. 4. bipolar depression breakthrough
    Quetiapine 300 mg QHS or lurasidone 40–120 mg with food or cariprazine 1.5–3 mg • PO • daily
    trigger: Depressive relapse during maintenance (APA 2024)
    First-line for bipolar depression; AVOID antidepressant monotherapy (STEP-BD Sachs NEJM 2007; APA 2024)

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Elevated/expansive/irritable mood + increased energy ≥1 week (mania) or ≥4 days (hypomania) (DSM-5-TR 2022 criterion A); 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).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Bipolar Disorder — acute mania + bipolar depression + maintenance (APA 2024; CANMAT/ISBD 2018; BALANCE Geddes Lancet 2010)** (psych.bipolar-disorder.core.v1).
Phenotype framing: Bipolar I vs II vs cyclothymia vs schizoaffective vs substance-induced mania vs hyperthyroidism vs steroid-induced mania vs ADHD vs borderline personality disorder vs MDD with mixed features (DSM-5-TR 2022; APA 2024)
Scope: Confirm DSM-5-TR 2022 bipolar I or II diagnosis — at least one manic (BP I) or hypomanic (BP II) episode; identify current episode polarity (manic, depressive, mixed, or euthymic maintenance) (APA 2024)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Acute mania pharmacotherapy — mood stabiliser + SGA (APA 2024; CANMAT/ISBD 2018 Yatham)** — step "Step 1 — Lithium or valproate monotherapy for mild-moderate mania (APA 2024; CANMAT/ISBD 2018)".
1. lithium 300 mg PO TID; target level 0.8–1.2 mmol/L PO TID with level monitoring (mood_stabiliser, first line) — 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)
2. valproate 500 mg PO BID or 20–30 mg/kg/day loading; target level 50–125 mcg/mL PO BID-TID with level monitoring (mood_stabiliser, first line) — First-line for acute mania especially mixed or rapid cycling; contraindicated in pregnancy (FDA 2013 black-box; APA 2024; CANMAT/ISBD 2018 Yatham)

Setting playbook (outpatient) — Maintain euthymia with lifelong mood stabiliser, prevent relapse, monitor for medication toxicity, psychoeducation + IPSRT/CBT (APA 2024; BALANCE Geddes Lancet 2010; CANMAT/ISBD 2018 Yatham)
3. lithium maintenance 300 mg BID–TID; target 0.6–0.8 mmol/L PO BID-TID with q3–6 mo levels — First-line maintenance for BP I (APA 2024; BALANCE Geddes Lancet 2010) (BALANCE (Geddes Lancet 2010): lithium superior to valproate; anti-suicide (Cipriani Lancet 2005); lifelong recommended for BP I (APA 2024))
4. lamotrigine for depression-predominant BP II maintenance 200 mg PO daily (slow titrate if starting) PO daily — BP II with depressive predominant polarity (APA 2024; CANMAT/ISBD 2018 Yatham) (Better at preventing depressive relapse; slow titration — SJS risk (Calabrese JCP 2003; APA 2024))
5. SGA maintenance adjunct Aripiprazole 10–15 mg or quetiapine 300–400 mg or aripiprazole LAI 400 mg monthly PO/IM daily or monthly (LAI) — Breakthrough on mood stabiliser monotherapy (APA 2024; CANMAT/ISBD 2018) (SGA augmentation for incomplete maintenance response (APA 2024; CANMAT/ISBD 2018 Yatham))
6. bipolar depression breakthrough Quetiapine 300 mg QHS or lurasidone 40–120 mg with food or cariprazine 1.5–3 mg PO daily — Depressive relapse during maintenance (APA 2024) (First-line for bipolar depression; AVOID antidepressant monotherapy (STEP-BD Sachs NEJM 2007; APA 2024))

Non-pharmacologic actions:
- Interpersonal and social rhythm therapy (IPSRT) — stabilise circadian rhythms (Frank Int J Bipolar Disord 2015; APA 2024)
- Cognitive-behavioural therapy for bipolar (CBT-BP) — reduces relapse (Miklowitz JAMA Psych 2007; APA 2024; NICE 2024)
- Family-focused therapy — early warning sign recognition, communication skills (Miklowitz JAMA Psych 2007; APA 2024)
- Psychoeducation — lifelong medication importance, trigger avoidance (sleep deprivation, substance use, travel), relapse signature (NICE 2024; APA 2024)
- Lifestyle: regular sleep-wake schedule, exercise 3–5×/week, alcohol avoidance, stress management (APA 2024; CANMAT/ISBD 2018)
- Advance directive / crisis plan collaboratively developed with patient and supports (APA 2024; NICE 2024)

AVOID / contraindication checks:
- Valproate_absolute_contraindication_pregnancy (FDA 2013 black box; APA 2024)
- Lithium_renal_impairment_dose_adjust_eGFR (APA 2024; KDIGO 2024)
- Lithium_dehydration_NSAID_ACE_diuretic_toxicity_risk (APA 2024)
- Olanzapine_IM_no_concurrent_IM_benzodiazepine (FDA; APA 2024)
- Ziprasidone_QTc_prolongation_ECG_required (FDA; APA 2024)
- Carbamazepine_HLA_B1502_asian_screen_SJS (FDA 2007; CANMAT/ISBD 2018)
- SGA_metabolic_monitoring_APA_ADA_2004
- Valproate_hepatotoxicity_LFT_monitoring (APA 2024; CANMAT/ISBD 2018)
- Lithium_narrow_therapeutic_index_level_monitoring (APA 2024)

Monitoring

Regimen monitoring:
- YMRS at days 3 7 14 21 for acute mania (APA 2024)
- Lithium level q5 7d titration then q3 6mo (APA 2024)
- Valproate level at day5 then q3 6mo (APA 2024; CANMAT/ISBD 2018)
- Renal function TSH q6mo on lithium (APA 2024)
- CBC LFT q6mo on valproate (APA 2024; CANMAT/ISBD 2018)
- SGA metabolic panel baseline 3mo 6mo annual (APA/ADA 2004)
- ECG if ziprasidone or QTc risk (FDA; APA 2024)

Setting (outpatient) monitoring:
- YMRS + PHQ-9/MADRS at every visit (APA 2024)
- C-SSRS at every visit (Posner 2011; APA 2024)
- Lithium level q3–6 mo steady state + q3–5 d after any dose change (APA 2024)
- Renal function (creatinine, eGFR) q6–12 mo on lithium (APA 2024; KDIGO 2024)
- TSH q6–12 mo on lithium (APA 2024)
- Valproate level + CBC + LFT q3–6 mo (APA 2024; CANMAT/ISBD 2018)
- SGA metabolic panel — A1c + lipids + weight q3–6 mo (APA/ADA 2004)
- Pregnancy test before prescribing valproate in reproductive-age women (FDA 2013; APA 2024)

Follow-up plan: 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)
- Close-out criterion: Maintenance plan in place with lifelong mood stabiliser (APA 2024)

Monitoring phase: Acute mania: YMRS at days 3, 7, 14, 21 (APA 2024); lithium level q5–7 d during titration then q3–6 mo (APA 2024); valproate level at day 5 then q3–6 mo; renal + TSH q6 mo on lithium; CBC + LFT q6 mo on valproate; SGA metabolic panel baseline/3 mo/6 mo/annual (APA/ADA 2004); bipolar depression: PHQ-9/MADRS q2–4 weeks (APA 2024)

Disposition

Current setting: outpatient — Maintain euthymia with lifelong mood stabiliser, prevent relapse, monitor for medication toxicity, psychoeducation + IPSRT/CBT (APA 2024; BALANCE Geddes Lancet 2010; CANMAT/ISBD 2018 Yatham)

Disposition criteria:
- Continue current regimen if euthymic with stable levels and tolerable side effects (APA 2024; BALANCE Geddes Lancet 2010)
- Breakthrough episode → re-enter acute treatment axis for relevant polarity (APA 2024)
- Refer to specialist bipolar clinic if rapid cycling, treatment-resistant, or complex comorbidity (APA 2024; CANMAT/ISBD 2018)

Escalation triggers (move to higher acuity):
- Rising YMRS or emerging mania → optimise mood stabiliser, add SGA, increase visit frequency (APA 2024)
- Active SI with intent/plan/means → ED referral (APA 2024)
- Psychotic symptoms → urgent psychiatry evaluation; consider inpatient (APA 2024)
- Lithium toxicity signs → hold lithium, check level, ED if severe (APA 2024)
- Medication non-adherence → explore barriers; consider LAI aripiprazole (Calabrese AJP 2017; APA 2024)
- Rapid cycling (≥4 episodes/year) → optimise mood stabiliser, discontinue any antidepressant, refer specialist (APA 2024; CANMAT/ISBD 2018)

Patient Action Plan

**Bipolar disorder self-management plan + early warning signs (APA 2024; NICE 2024; CANMAT/ISBD 2018)**
Personalised values: current_mood_stabiliser_and_dose, identified_triggers, early_warning_signs, crisis_plan_contacts, advance_directive_status, sleep_target.

**Doing well — euthymic, stable sleep, adherent to medication (APA 2024)** (green):
Triggers:
- 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)
Actions:
- 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)

**Caution — early warning signs of mood shift (mania or depression) (APA 2024; NICE 2024)** (yellow):
Triggers:
- 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)
Actions:
- 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)
Contact provider when:
- 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)

**Medical alert — active mania/psychosis, active SI, lithium toxicity, NMS (APA 2024)** (red):
Triggers:
- 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)
Actions:
- 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)
Contact provider when:
- Any red zone trigger — emergency department immediately (APA 2024)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] C-SSRS positive for active SI with intent, plan, or recent preparatory behaviour in bipolar patient (Posner 2011; APA 2024)
- [LIFE_THREATENING] 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)

Citations

- APA Practice Guideline for Bipolar Disorder 2024 + CANMAT/ISBD 2018 (Yatham Bipolar Disord) + NICE CG185 2024 update [PMID:17392295](https://pubmed.ncbi.nlm.nih.gov/17392295/)
- Cited evidence (PMID 20092882) [PMID:20092882](https://pubmed.ncbi.nlm.nih.gov/20092882/)
- Cited evidence (PMID 29536616) [PMID:29536616](https://pubmed.ncbi.nlm.nih.gov/29536616/)
- Cited evidence (PMID 16199826) [PMID:16199826](https://pubmed.ncbi.nlm.nih.gov/16199826/)
- Cited evidence (PMID 17110817) [PMID:17110817](https://pubmed.ncbi.nlm.nih.gov/17110817/)

Last reconciled with current guidelines: 2026-05-14.
References
  • APA Practice Guideline for Bipolar Disorder 2024 + CANMAT/ISBD 2018 (Yatham Bipolar Disord) + NICE CG185 2024 update — PMID:17392295
  • Cited evidence (PMID 20092882) — PMID:20092882
  • Cited evidence (PMID 29536616) — PMID:29536616
  • Cited evidence (PMID 16199826) — PMID:16199826
  • Cited evidence (PMID 17110817) — PMID:17110817