A long-term psychiatric follow-up process for individuals diagnosed with Bipolar I and II, conducted with mood stabilizers such as lithium, valproate or atypical antipsychotics to prevent and manage manic, hypomanic and depressive episodes.
Indication
- Bipolar I disorder (history of at least one manic episode; severe elevation, decreased need for sleep, risky behaviors)
- Bipolar II disorder (co-occurrence of hypomania and major depressive episodes)
- Cyclothymic disorder (mild but long-lasting mood fluctuations)
- Relapse prevention after recurrent mood episodes (maintenance treatment)
- Individuals who have experienced a hypomanic / manic switch while taking antidepressants
- Those with a history of bipolar episodes in the postpartum period
- Individuals with a family history of bipolar disorder who experience mood fluctuations
Preparation
- Detailed psychiatric history; onset, duration and severity of past episodes and family history
- If lithium is to be started — kidney function tests, thyroid function tests, ECG, pregnancy test
- If valproate is to be started — liver function tests, complete blood count, pregnancy status (teratogenic risk)
- If an atypical antipsychotic is being considered — weight, waist circumference, fasting glucose, lipid profile
- Sharing all medications used (especially antidepressants) and information about substance use
How it's performed
- Bipolar I, II or cyclothymic disorder is differentiated according to DSM-5 / ICD-10 diagnostic criteria
- In acute mania, lithium, valproate or an atypical antipsychotic (quetiapine, olanzapine, aripiprazole, risperidone) is selected; combinations may be used if agitation is prominent
- In bipolar depression, options such as lithium, quetiapine, lurasidone and lamotrigine are evaluated; antidepressant monotherapy may trigger a manic switch and is given carefully under cover of a mood stabilizer
- In maintenance therapy, lithium has the strongest evidence for relapse prevention; alternatives are chosen according to tolerance and response
- Psychoeducation and family information — early recognition of episode signs, sleep regulation, avoiding triggers
- Cognitive behavioral therapy and Interpersonal and Social Rhythm Therapy (IPSRT) support treatment
Post-procedure
- Monthly or every 2-3 months in stable periods; weekly follow-up during acute periods
- For those on lithium, blood level (target 0.6-1.0 mmol/L), kidney and thyroid tests every 3-6 months
- For those on valproate, monitoring of liver and platelets; planning is important due to teratogenic risk during pregnancy
- For those on atypical antipsychotics, monitoring of weight, waist circumference, glucose and lipids
- Family members are taught 'early warning signs' (decreased sleep, excessive talking, spending sprees, increased energy); suicide risk is monitored
Risks
- Lithium: tremor, kidney-thyroid dysfunction; toxicity (>1.5 mmol/L) may cause nausea, ataxia and altered consciousness
- Valproate: weight gain, hair loss, thrombocytopenia, elevated liver enzymes; risk of neural tube defects in pregnancy
- Atypical antipsychotics: sedation, weight gain, metabolic syndrome, extrapyramidal side effects
- Risk of manic/hypomanic switch when starting antidepressants (especially when given without protection)
- Treatment non-adherence or abrupt discontinuation — recurrence of episodes (relapse), occupational and social losses; increased suicide risk
FAQ
Will I take medication for bipolar disorder for the rest of my life?
In Bipolar I disorder, after recurrent episodes, long-term — often lifelong — maintenance treatment is generally recommended. Treatment significantly reduces the risk of relapse.
Is lithium dangerous?
Lithium is an effective medication; however, blood levels and kidney-thyroid function must be monitored regularly. With appropriate dosing and follow-up, it can be used safely.
Do I need to be hospitalized during a manic episode?
Hospitalization may be needed in case of severe mania, psychotic symptoms, or risk of suicide or harm to others. Outpatient treatment may be possible in mild to moderate hypomania.
I am planning pregnancy — can I stop the medication?
In bipolar disorder, pregnancy planning must be done together with the psychiatrist. Some medications (especially valproate) have teratogenic effects; the treatment plan and medication choice are reorganized before pregnancy. Do not stop treatment on your own.
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