Adjunctive treatment generally is recommended for patients who do not sufficiently respond to antimanic monotherapy after one to two weeks. If the patient stabilizes on combination therapy (e.g., divalproex and an atypical antipsychotic) and tolerates the treatment, the combination regimen should continue for one to two years. If tolerability concerns (e.g., weight gain, menstrual irregularities) make a patient hesitant to accept either treatment, consider engaging a psychiatric consultation as treatment moves into the continuation/maintenance phase.
Most primary care practitioners initiate treatment for bipolar disorder while the patient is actively depressed. The evidence presented in Table 2 is an important guide to selecting and sequencing treatment. Antidepressant monotherapy is generally discouraged because it can destabilize bipolar disorder. First-line medications for bipolar depression are lithium, lamotrigine or an atypical antipsychotic, such as quetiapine. Adding an antidepressant to these first-line medications is suggested for severe depression.