Synopsis
Build individual relapse prevention after each bipolar episode using lithium-first pharmacology, structured psychological treatment, physical-health protection and a written plan for early warning signs, medication change and safe discontinuation.
- After every manic or bipolar depressive episode, review long-term prevention, previous consequences, residual symptoms, effective treatments, patient priorities and reproductive plans.
- Offer a structured individual, group or family psychological intervention designed for bipolar disorder to prevent relapse or address persisting inter-episode symptoms.
- First-line long-term pharmacological treatment is lithium; NICE explains that it is the most effective maintenance medicine for bipolar disorder.
- If lithium is ineffective, poorly tolerated or unsuitable, consider one appropriate antipsychotic; if that trial fails or causes rapid weight gain, consider another recommended antipsychotic.
- Only after the alternative antipsychotic is ineffective should valproate combination with an antipsychotic or lithium be considered, subject to all current MHRA restrictions.
- Use the person's episode history to identify a relapse signature: earliest sleep, energy, thought, activity, spending, social and depressive changes, not generic warning lists.
- Agree coping actions, who may receive information, named primary and secondary care contacts and circumstances for urgent review or a pre-agreed medication response.
- If long-term medication stops, taper according to the medicine-specific schedule, teach early signs and continue mood and mental-state monitoring for two years after it ends completely.
- Provide at least annual comprehensive physical-health review, with additional drug-specific lithium, antipsychotic or valproate monitoring at the required frequency.
Key red flags
A rapid fall in sleep need with increasing energy, speech or spending can precede mania and requires prompt use of the agreed escalation plan.
Hopelessness, withdrawal, stockpiling medication, farewell behaviour or renewed self-harm overrides the timetable for ordinary relapse-prevention review.
Pregnancy, planning pregnancy or a partner-conception plan can materially alter lithium or valproate decisions and requires timely specialist review without abrupt self-discontinuation.
Vomiting, diarrhoea, dehydration, new interacting medicines, ataxia, coarse tremor or confusion during lithium treatment suggests toxicity risk and needs urgent action.
Rapid weight gain, new hyperglycaemic symptoms, syncope, severe movement disorder or other medically important antipsychotic effects require earlier physical and prescription review.
Investigation priorities
Map polarity, frequency, severity, triggers, harms, recovery and previous treatment response across the illness.
Management branches
Long-term medication is being planned after a bipolar episode and lithium is acceptable and clinically suitable.
- Discuss episode history, lithium's relative long-term effectiveness, monitoring burden, toxicity, interactions, pregnancy implications and the person's priorities.
- Complete baseline tests, establish specialist initiation and shared-care responsibilities and titrate to a guideline target using correctly timed plasma levels.
- Combine medicine with structured psychological prevention, physical-health care and a written relapse and sick-day action plan.
A stable patient makes an informed decision to stop long-term pharmacological treatment.
- Review relapse history, current stress, pregnancy plans, alternatives and the medicine-specific withdrawal schedule and agree early-warning actions.
- Reduce gradually at the required medicine-specific pace with closer symptom and safety review during and after the taper.
- Continue monitoring mood, symptoms and mental state for two years after treatment stops completely and preserve rapid re-entry to specialist care.