Managing Bipolar Disorder: A Pharmacist’s Guide to Goals of Therapy, Medication Management, and Collaboration

Ashley Y, PharmD

July 6, 2025

Bipolar disorder isn’t just bad days and good days — it's extreme mood swings that can be physically, mentally and emotionally exhausting. As pharmacists, we’re in a prime position not only to support patients, but to shape treatment decisions, counsel patients, and ensure adherence.

Goals of Therapy

According to the CANMAT‑ISBD guidelines (2018), the core goals of bipolar treatment are:

1. Acute phase control — stop mania or depression as quickly and safely as possible.

2. Maintenance phase stabilization — maintain mood equilibrium and enable functional living.

3. Relapse prevention — minimize new mood episodes and reduce hospitalizations.

4. Suicide prevention — aggressive prevention strategy for mood disorder patients.

5. Improve quality of life and functioning — social, occupational, and personal health.

   
   

Algorithms

As per the CPS, see below for the algorithms to manage:

1. acute mania in bipolar disorder

2. depressive episodes in bipolar disorder

3. maintenance therapy for bipolar disorder

How the algorithm works:

1. Acute Phase — Use mood stabilizer with or without antipsychotic

2. Stabilize Patient — Achieve symptom control, taper adjunctive agents after remission

3. Maintenance — Continue stabilizers (e.g., Lithium or Quetiapine) for 6+ months

4. Relapse Management — Adjust therapy based on new symptoms, adherence, or side effects

First and Second Line Therapy

Phase	First‑Line	Second‑Line / Alternatives
Acute Mania	Lithium, Valproate, Quetiapine, Risperidone, Aripiprazole	Haloperidol, Carbamazepine, Olanzapine, Ziprasidone
Acute Depression	Lithium, Quetiapine, Lamotrigine	Lurasidone, Olanzapine+Fluoxetine combo
Maintenance	Lithium, Quetiapine, Valproate, Lamotrigine	Carbamazepine, Aripiprazole, Other SGAs (e.g. Risperidone)

Pharmacologic Profiles & Monitoring Needs

Here are the top psych meds organized by class. This is but a very brief overview of the medications, so I always like to have the CPS open when I am counselling patients.

Mood Stabilizers

• Lithium

  • Dose: 900–1,800 mg/day in divided doses

  • Monitor: Trough serum levels (0.6–1.2 mmol/L), eGFR, CrCl, TSH, QTc

  • Counsel: Hydration, toxicity signs (tremor/confusion), birth control for females - risk vs benefit of lithium in pregnancy

• Valproic Acid / Divalproex

  • Dose: 750–2,000 mg/day

  • Monitor: LFTs, CBC, weight

  • Counsel: Avoid in pregnancy; GI upset, hepatotoxicity, thrombocytopenia risk

• Lamotrigine

  • Dose: Slow titration to 200 mg/day

  • Monitor: Rash, hypersensitivity (SJS/TEN warning)

  • Counsel: May cause drowsiness (can take at bedtime), rash requires stopping immediately

Atypical Antipsychotics

• Quetiapine

  • Dose - mania: 200mg-400mg BID (mania)

  • Dose - depression/maintenance: 300-600 mg/day (opt for XR formulation to improve adherence)

  • Monitor: Weight, sedation, dizziness/hypotension, movement disorders

  • Counsel: Watch for weight gain, hydration, heat stroke protection, drowsiness

• Risperidone

  • Dose - mania: 3-6mg/day as a single dose or div BID (start at 2-3mg/day)

  • Monitor: EPS, weight, temperature dysregulation

  • Counsel: Watch for weight gain, hydration, heat stroke protection, drowsiness

• Aripiprazole

  • Dose - mania/maintenance: 10-15mg/day

  • Monitor: akithisia, dizziness, hypotension, tremor

  • Counsel: Watch for movement disorders, restlessness, dizziness, tremor

Antidepressants (Adjunctive)

• Only with mood stabilizer

• SSRIs or bupropion for bipolar depression

• Monitor: Risk of manic switch—even with stabilization in place

• Counsel: Use lowest effective dose; warn about mood fluctuations

Pharmacist’s Role in the Care Team

As pharmacists, we can help our patients by:

• Simplifying Medication Regimens: Recommending to the physician long acting formulations/injections to improve adherence, blister packaging, and having honest conversations with patients regarding reasons for non-adherence

• Therapeutic Monitoring: Flag lab work (Li, LFT, TSH), ensure baseline ECGs for patients on QT-altering agents

• Drug Interaction Oversight: Watch for dangerous combinations (e.g., QT prolongers, CYP450 interactions)

• Education & Counselling: Educate on how to monitor for side effects and what to do, encourage lifestyle modifications

• Proactive Screening: Keep tabs on weight, glucose, lipids—inform prescriber if metabolic issues emerge

• Collaboration & Advocacy: Communicate with prescribers to recommend first-line agents or dosage adjustments

  
  

Managing bipolar disorder is complex—but it’s exactly why its so important as pharmacists, who are the most accessible healthcare provider, to stay involved. We play a pivotal role in monitoring, educating, and collaborating with prescribers to create safer, more effective treatment plans. Lean on resources like the CANMAT–ISBD 2018 guidelines and the CPS to ground your decisions. Keep a close eye on labs, ECGs, and potential drug interactions. Use every patient encounter as a chance to educate on side effects, set realistic expectations, and encourage adherence. With regular follow-ups and a proactive approach, we can help prevent relapse, reduce hospital readmissions, and empower patients on their journey to a better health and happiness.