Clinical Management and Treatment Strategies for Bipolar Affective Disorder

Bipolar Affective Disorder (BAD) is a chronic, recurrent, and disabling psychiatric condition affecting more than 2% of the world’s population, characterized by episodes of mania, hypomania, depression, and mixed states interspersed with periods of euthymia. Of particular note is the high mortality rate due to suicide, with lifetime suicide attempt rates ranging from 30% to 50% and a risk of completed suicide 10 to 30 times higher than that of the general population, with higher lethality during depressive and mixed phases. This is a narrative literature review based on a search of PubMed/MEDLINE covering the last five years, in English and Portuguese, using the MeSH terms “Bipolar Disorder” and “Therapeutics.” The review showed that, for acute mania, guidelines recommend lithium, divalproate, and atypical antipsychotics (such as quetiapine and risperidone) as first-line treatments, with combination regimens being superior in severe or psychotic cases. In bipolar depression, which is more complex, quetiapine, cariprazine, lurasidone, and the olanzapine-fluoxetine combination stand out, while the use of antidepressants as monotherapy in Type I bipolar disorder is contraindicated due to the risk of a manic switch. For prophylaxis, lithium remains the gold standard due to its independent antisuicidal effect, followed by lamotrigine, quetiapine, and long-acting injectable antipsychotics. For cases refractory to conventional therapy, electroconvulsive therapy and clozapine are the primary alternative or adjunctive strategies, which must be combined with ongoing psychoeducation. Management requires a hierarchical algorithm tailored to each treatment center and age group, combining mood stabilizers, atypical antipsychotics, and psychosocial strategies to achieve clinical stabilization, restore functionality, and reduce mortality.