HOW TO TREAT BIPOLAR AFFECTIVE DISORDER 2025

HOW TO TREAT BIPOLAR AFFECTIVE DISORDER 2025

GUIDELINES FOR THE DIAGNOSIS AND TREATMENT OF COMMON MENTAL DISORDERS

(Enacted under Decision No. 2058/QĐ-BYT dated May 14, 2020, by the Minister of Health)

Article 19

BIPOLAR AFFECTIVE DISORDER

CHIEF EDITOR

Associate Professor, PhD Nguyễn Trường Sơn

CO-EDITOR

Associate Professor, PhD Lương Ngọc Khuê

PhD Nguyễn Doãn Phương

CONTRIBUTING AUTHORS

PhD Trần Thị Hà An

MSc Trịnh Thị Vân Anh

PhD Vũ Thy Cầm

MSc Trần Mạnh Cường

PhD Nguyễn Văn Dũng

PhD Vương Ánh Dương

PhD Lê Thị Thu Hà

MSc Trần Thị Thu Hà

MSc Phạm Công Huân

MSc Đoàn Thị Huệ

Specialist Doctor II Nguyễn Thị Minh Hương

MSc Vũ Thị Lan

1. Nguyễn Phương Linh

Specialist Doctor II Nguyễn Thị Phương Loan

MSc Bùi Văn Lợi

MSc Nguyễn Thị Phương Mai

PhD Trần Nguyễn Ngọc

MSc Bùi Nguyễn Hồng Bảo Ngọc

MSc Trương Lê Vân Ngọc

MSc Bùi Văn San

PhD Dương Minh Tâm

MSc Phạm Xuân Thắng

MSc Lê Thị Phương Thảo

MSc Lê Công Thiện

MSc Vương Đình Thủy

Associate Professor, PhD Nguyễn Văn Tuấn

Specialist Doctor II Ngô Văn Tuất

MSc Đặng Thanh Tùng

MSc Vũ Sơn Tùng

MSc Cao Thị Ánh Tuyết

MSc Nguyễn Thị Ái Vân

Specialist Doctor II Hồ Thu Yến

MSc Nguyễn Hoàng Yến

CONTRIBUTORS TO EVALUATION AND FEEDBACK

Associate Professor, PhD Nguyễn Thanh Bình

PhD Vũ Thy Cầm

PhD Nguyễn Hữu Chiến

Specialist Doctor II Võ Thành Đông

PhD Lê Thị Thu Hà

Specialist Doctor II Đỗ Huy Hùng

PhD Nguyễn Mạnh Hùng

MSc Nguyễn Trọng Khoa

Specialist Doctor II Ngô Hùng Lâm

Associate Professor, PhD Phạm Văn Mạnh

Specialist Doctor II Trần Ngọc Nhân

PhD Dương Minh Tâm

MSc Đặng Duy Thanh

PhD Vương Văn Tịnh

Specialist Doctor II Lâm Tứ Trung

PhD Lại Đức Trường

PhD Cao Văn Tuân

Associate Professor, PhD Nguyễn Văn Tuấn

SECRETARIAT TEAM

MSc Đặng Thanh Tùng

MSc Trương Lê Vân Ngọc

BA Đỗ Thị Thư

Article 19

BIPOLAR AFFECTIVE DISORDER

I. DEFINITION  

Bipolar affective disorder is a chronic mood disorder characterized by alternating or co-occurring episodes of mania or hypomania and depression. Also known as manic-depressive disorder or bipolar spectrum disorder, it is defined by ICD-10 as involving at least two distinct episodes of significant mood and activity disturbance—periods of elevated mood, energy, and activity (hypomania or mania) interspersed with periods of reduced mood, energy, and activity (depression). Recurrent episodes of mania or hypomania alone are also classified as bipolar disorder.

II. ETIOLOGY  

1. Biological Factors:  

   – Epidemiological and genetic evidence indicates a strong hereditary component, with prevalence relatively stable across individuals and social conditions.  

   – Dysregulation of the hypothalamic-pituitary-adrenal axis and thyroid abnormalities.  

   – Neurotransmitter/receptor imbalances, particularly in the dopamine system.  

2. Environmental Factors:  

   – Environmental influences are critical, as identical twins do not always both develop the disorder.  

   – Negative life events and chronic stress are linked to the onset and recurrence of mood episodes, often preceding both manic/hypomanic and depressive phases.  

3. Neuroimaging Insights:  

   – Hyperactivity of the hypothalamic-pituitary-adrenal axis during depressive phases and evidence of thyroid dysfunction with antithyroid antibodies in some patients.  

   – Deficits in neuronal and glial cell density, glial activity, neuronal structure/integrity, and biochemical changes in the prefrontal cortex, with altered connectivity to other cortical regions.  

   – Increased baseline activity in the ventral striatum and amygdala, thalamic dysregulation, and relative cerebellar hyperactivity.

III. DIAGNOSIS  

1. Definitive Diagnosis (ICD-10)  

– Bipolar Disorder, Current Episode Hypomanic (F31.0):  

  – Current episode meets hypomania criteria (F30.0).  

  – Past history of at least one mood episode (hypomania, mania, depression).  

– Bipolar Disorder, Current Episode Manic Without Psychotic Symptoms (F31.1):  

  – Current episode meets mania criteria without psychosis (F30.1).  

  – Past history of at least one mood episode (hypomania, mania, depression).  

– Bipolar Disorder, Current Episode Manic With Psychotic Symptoms (F31.2):  

  – Current episode meets mania criteria with psychosis (F30.2).  

  – Past history of at least one mood episode (hypomania, mania, depression).  

– Bipolar Disorder, Current Episode Mild or Moderate Depression (F31.3):  

  – Current episode meets mild (F32.0) or moderate (F32.1) depression criteria.  

  – Past history of at least one hypomanic or manic episode.  

– Bipolar Disorder, Current Episode Severe Depression Without Psychotic Symptoms (F31.4):  

  – Current episode meets severe depression criteria without psychosis (F32.2).  

  – Past history of at least one hypomanic or manic episode.  

– Bipolar Disorder, Current Episode Severe Depression With Psychotic Symptoms (F31.5):  

  – Current episode meets severe depression with psychosis criteria (F32.3).  

  – Past history of at least one hypomanic, manic, or mixed episode.  

– Bipolar Disorder, Current Episode Mixed (F31.6):  

  – Current episode involves rapid alternation or blending of hypomanic/manic and depressive symptoms.  

  – Past history of at least one hypomanic or manic episode.  

– Bipolar Disorder, Currently in Remission (F31.7):  

  – No significant current mood disturbance.  

  – Past history of at least one mood episode (hypomania, mania, depression).  

2. Differential Diagnosis  

– Major depressive disorder or dysthymia.  

– Mood disorder due to a medical condition.  

– Substance-induced mood disorder.  

– Cyclothymic disorder.  

– Psychotic disorders (schizoaffective disorder, schizophrenia, delusional disorder).  

– Borderline personality disorder.  

– Narcissistic personality disorder.  

– Antisocial personality disorder.  

3. Ancillary Testing  

3.1. Basic Labs  

– Blood: Hematology, biochemistry, microbiology (HIV, HBV, HCV).  

– Urine: General analysis, drug screening, syphilis serology.  

– Thyroid hormone levels.  

3.2. Imaging/Functional Tests  

– Chest X-ray, abdominal ultrasound.  

– EEG, ECG, cerebral blood flow, transcranial Doppler.  

– CT/MRI brain (select cases).  

3.3. Psychological Assessments  

– Depression scales: Beck, Hamilton, GDS, PHQ-9.  

– Young Mania Rating Scale (YMRS).  

– Personality: MMPI, EPI.  

– Pittsburgh Sleep Quality Index (PSQI).  

– Anxiety scales: Zung, Hamilton, DASS.  

3.4. Monitoring Tests  

– Metabolic effects: Blood glucose, lipids (cholesterol, triglycerides, LDL, HDL) every 3 months.  

– Leukopenia: Complete blood count monthly.  

– Liver, kidney function, ECG every 3 months.  

– HLA-B*1502 genetic testing for antiepileptic drug allergy risk (e.g., carbamazepine).

IV. TREATMENT  

1. Treatment Principles  

– Early hospitalization for severe episodes, especially depression with suicidal ideation; outpatient care for mild cases.  

– Detect early mood disturbances for timely intervention.  

– Assess severity, clinical structure, and psychotic symptoms.  

– Initiate prompt treatment: antidepressants for depression, antipsychotics for mania, and mood stabilizers, tailoring drug choice and dosage.  

– Use sedatives as needed.  

– Prevent relapse post-acute phase with psychosocial rehabilitation.  

– Maintain treatment for at least 6 months to prevent recurrence.  

2. Treatment Framework  

2.1. Pharmacotherapy  

– Acute Manic/Hypomanic/Mixed Episodes:  

  – Mood Stabilizers: 1-3 agents:  

    – Divalproex (750 mg/day – 60 mg/kg/day).  

    – Valproate (500-2000 mg/day).  

    – Carbamazepine (200-1600 mg/day).  

    – Oxcarbazepine (600-2400 mg/day).  

    – Lamotrigine (100-400 mg/day).  

    – Topiramate (50-400 mg/day).  

    – Gabapentin (300-1800 mg/day).  

  – Antipsychotics: 1-3 agents:  

    – Typical:  

      – Haloperidol (5-30 mg/day).  

      – Chlorpromazine (25-500 mg/day).  

      – Levomepromazine (25-500 mg/day).  

    – Atypical:  

      – Risperidone (1-10 mg/day).  

      – Olanzapine (5-30 mg/day).  

      – Quetiapine (200-800 mg/day).  

      – Clozapine (300-900 mg/day).  

      – Aripiprazole (5-30 mg/day).  

  – Benzodiazepines: 1 agent:  

    – Diazepam (5-30 mg/day).  

    – Lorazepam (1-4 mg/day).  

    – Clonazepam (1-8 mg/day).  

    – Bromazepam (3-6 mg/day).  

  – Combination: For severe mania or psychosis, combine mood stabilizers (e.g., valproate, carbamazepine) with antipsychotics.  

– Acute Depressive Episodes:  

  – Mood Stabilizers: 1-3 agents:  

    – Lamotrigine (100-400 mg/day).  

    – Divalproex (750 mg/day – 60 mg/kg/day).  

    – Valproate (500-1500 mg/day).  

    – Carbamazepine (200-1600 mg/day).  

    – Oxcarbazepine (600-2400 mg/day).  

    – Topiramate (50-400 mg/day).  

    – Gabapentin (300-1800 mg/day).  

  – Antidepressants: 1-3 agents:  

    – TCAs:  

      – Amitriptyline (25-200 mg/day).  

      – Clomipramine (50-100 mg/day).  

    – SSRIs:  

      – Sertraline (50-300 mg/day).  

      – Fluoxetine (20-60 mg/day).  

      – Fluvoxamine (50-100 mg/day).  

      – Citalopram (20-60 mg/day).  

      – Escitalopram (10-20 mg/day).  

      – Paroxetine (20-80 mg/day).  

    – SNRIs:  

      – Venlafaxine (37.5-225 mg/day).  

      – Duloxetine (40-120 mg/day).  

    – NaSSAs:  

      – Mirtazapine (15-60 mg/day).  

    – Dopamine-Norepinephrine Reuptake Inhibitors:  

      – Bupropion (75-450 mg/day).  

  – Antipsychotics: 1-3 agents:  

    – Typical:  

      – Haloperidol (5-30 mg/day).  

      – Chlorpromazine (25-500 mg/day).  

      – Levomepromazine (25-500 mg/day).  

    – Atypical:  

      – Risperidone (1-10 mg/day).  

      – Olanzapine (5-30 mg/day).  

      – Quetiapine (50-800 mg/day).  

      – Clozapine (25-900 mg/day).  

      – Aripiprazole (5-30 mg/day).  

– Maintenance Phase: Use effective acute-phase drugs:  

  – Valproate (200-500 mg/day).  

  – Carbamazepine (200-400 mg/day).  

  – Risperidone (2 mg/day).  

  – Olanzapine (10 mg/day).  

  – Quetiapine (100 mg/day).  

– Adjunctive Treatments: Anxiolytics/sedatives (etifoxine, grandaxin, zopiclone, eszopiclone, hydroxyzine, beta-blockers), neuroprotectants (piracetam, citicoline, ginkgo biloba, vinpocetine, choline alfoscerate, cinnarizine), vitamins/minerals.  

2.2. Electroconvulsive Therapy (ECT)  

– Indicated for:  

  – Severe, agitated mania unresponsive to drugs.  

  – Severe depression with intense suicidal ideation/behavior or treatment resistance.  

2.3. Transcranial Magnetic Stimulation (TMS)  

– Preferred for mild to moderate depression, with strict adherence to indications and contraindications to minimize risks.  

2.4. Psychosocial Interventions  

– Cognitive-Behavioral Therapy (CBT).  

– Family therapy.  

– Social therapy.  

– Mental health education.  

V. PROGNOSIS AND COMPLICATIONS  

– Bipolar disorder is recurrent and often persistent, with relapse rates around 75%. Functional recovery lags behind symptom resolution, even after a single manic episode.  

– High mortality risk due to complications from risky behaviors, comorbid medical conditions, and suicide.  

VI. PREVENTION  

– Early intervention improves occupational/social functioning, maintains productivity, enhances quality of life, reduces healthcare costs, and lowers morbidity/mortality. It may alter the illness course.  

– Early detection of relapse signs for timely intervention.  

– Treatment adherence reduces recurrence, hospitalizations, suicide rates, and episode severity.

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