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Clinical Pathway

Bipolar Disorder — Recognition & Treatment

Often mistaken for depression; treatment differs by phase

Field: Mental HealthCode: MH-02AUpdated: June 2026Reference: RANZCP Mood Disorders CPG
Lithium remains the only mood stabiliser with a proven anti-suicide effect. Lamotrigine is now PBS-listed for bipolar disorder (from May 2026, restricted benefit). Avoid antidepressant monotherapy — it risks a switch into mania, hypomania or a mixed state.

Recognising bipolar

  • Mania (Bipolar I): ≥7 days of elevated or irritable mood, increased energy, reduced need for sleep, grandiosity, risk-taking.
  • Hypomania (Bipolar II): ≥4 days — similar features to mania but without severe impairment or psychosis.
  • Bipolar depression: often the presenting episode — hypersomnia, hyperphagia and leaden fatigue, rather than the insomnia and poor appetite typical of unipolar depression.
  • Mixed features: depression plus agitation or racing thoughts — a materially higher suicide risk than either pole alone.
  • Screening clues: family history, an antidepressant-induced switch to mania or hypomania, younger age of onset, or repeated antidepressant failures.

Treatment by phase (RANZCP)

Specialist-led; cease antidepressants in mania, avoid AD monotherapy in bipolar depression.

1
Acute mania: lithium, valproate, quetiapine, aripiprazole or risperidone — often a mood stabiliser plus antipsychotic in combination; cease antidepressants.
2
Bipolar depression: quetiapine, lithium or lamotrigine are the best-supported options available in Australia — avoid antidepressant monotherapy.
3
Maintenance/prevention: lithium (the only agent with a proven anti-suicide effect), lamotrigine, quetiapine or valproate.
4
Mixed features: antipsychotic plus mood stabiliser, avoiding antidepressants — the higher suicide risk warrants urgent specialist review.
Valproate & childbearing potential. Sodium valproate is a teratogen, and recent data link paternal use in the months before conception to neurodevelopmental risk in the child. Avoid in people of childbearing potential unless no other treatment is suitable, and co-prescribe effective contraception. Confirm current product information at the TGA eBS or AMH before prescribing.

Safety

  • Don't treat bipolar depression with an antidepressant alone — it risks precipitating mania, hypomania or rapid cycling.
  • Avoid valproate in people of childbearing potential unless no other option is suitable, with effective contraception co-prescribed.
  • Mixed features carry a materially higher suicide risk than a pure manic or depressive episode — assess risk explicitly at every review.

Red flags / refer

  • First manic episode → urgent psychiatry referral; admission is often needed for acute mania.
  • Suicidal ideation during a depressive or mixed episode, or rapid cycling → urgent psychiatric assessment.
  • Diagnosis suspected but unconfirmed → refer for specialist-led diagnosis; phase-based treatment is specialist-initiated, not a general-practice task.

MH-02A v1.0 · Reviewed Jun 2026 · Review Jun 2027

For health-professional use. Framework: RANZCP Clinical Practice Guidelines for Mood Disorders (2015, updated 2020). Companion sheet: MH-02B Lithium Monitoring & Share-Care. Lamotrigine PBS-listed for bipolar disorder from May 2026.