Bipolar disorder: recognition, lithium monitoring, and GP shared care

What bipolar disorder is

Bipolar disorder is a chronic, recurrent mood disorder defined by episodes of mania or hypomania in addition to depressive episodes. It is not simply severe mood swings — the episodes are distinct, often prolonged, and cause substantial impairment. Bipolar I requires at least one lifetime manic episode (≥7 days of elevated or irritable mood with significant functional disruption or psychosis). Bipolar II requires at least one hypomanic episode plus a major depressive episode, without ever meeting full mania criteria. Cyclothymic disorder involves chronic subthreshold fluctuation over at least two years.

The condition affects approximately 1–4% of Australians across the spectrum, with equal sex prevalence (though depression episodes are more common in women). Peak onset is 15–25 years. The average diagnostic delay from first episode to correct diagnosis is approximately 10 years — largely because presentations, particularly in Bipolar II, are dominated by depression and the hypomanic periods may not seem problematic to the patient.

Two clinical consequences make accurate diagnosis urgent. First, bipolar disorder carries the highest lifetime suicide rate of any psychiatric disorder — approximately 10–15% — and significantly elevated risk of suicide attempt (RANZCP 2020 Mood Disorders Clinical Practice Guideline). Second, antidepressant monotherapy in undiagnosed bipolar is a recognised pathway to harm — inducing mania, mixed states, or rapid cycling.

A. Core clinical — the AU general-practice framework

The GP role in bipolar disorder

Bipolar disorder is primarily a specialist (psychiatry)-led condition. The GP role encompasses: recognising possible bipolar in depressed patients, screening before antidepressant prescribing, shared monitoring during stable phases, comorbidity management, early relapse identification, and crisis coordination.

Per eTG Psychotropic and RACGP mental health resources, GPs should not initiate mood stabilisers or atypical antipsychotics for bipolar without psychiatric input — but the GP is often the first clinician to encounter the condition.

MDQ screening — before every antidepressant

The Mood Disorder Questionnaire (MDQ) is a 13-item, 1-minute screen asking about lifetime mania and hypomania symptoms. Scoring ≥7 items positive, plus functional impairment, plus concurrent symptoms = positive screen. A positive result requires structured psychiatric review before proceeding with antidepressant treatment.

Australian prescribing guidance recommends applying the MDQ to all patients presenting with depression — particularly those with early-onset depression, previous antidepressant failures, family history of bipolar or mania, or episodes with racing thoughts, reduced sleep, or unusual decision-making alongside the low mood.

History

• Full mood episode history: manic, hypomanic, depressive, mixed; duration, severity, hospitalisation, impact on work and relationships.
• Triggering factors: sleep deprivation, significant life stress, recreational drug use, prior antidepressant exposure (did it trigger a switch?).
• Suicide and self-harm history — mandatory at every review given the elevated lifetime risk.
• Family history of bipolar, mania, or suicide.
• Comorbidities: substance use (very common in bipolar), anxiety, ADHD, eating disorders.
• Drug history: antidepressants, corticosteroids, stimulants (all can trigger mood episodes).
• Pregnancy planning — critical for medication choice.

Investigations

• MDQ in all depressed patients.
• Bloods: FBC, UEC, LFT, TSH, calcium, magnesium, vitamin D, B12, glucose, HbA1c, lipids.
• Pre-lithium baseline: eGFR, electrolytes, calcium, TSH, urinalysis, weight, ECG, pregnancy test.
• ECG before lithium, tricyclics, or QT-prolonging antipsychotics.
• Urine drug screen if substance use suspected.
• Brain CT or MRI for first-episode mania in older adults to exclude organic cause (stroke, CNS tumour, thyroid disease).

B. Lithium — gold standard and the safety essentials

Why lithium first

Lithium is endorsed as first-line maintenance by the RANZCP 2020 CPG, eTG Psychotropic, AMH, and NICE CG185. The BALANCE trial (Lancet 2010) demonstrated superiority of lithium over valproate for relapse prevention in bipolar I. Most distinctively, lithium is the only psychiatric medication with robust evidence for suicide prevention — a 60% relative reduction in suicide risk in a meta-analysis of 48 RCTs (Cipriani BMJ 2013).

Lithium carbonate (Quilonum SR, Lithicarb) is on the general PBS schedule at approximately $15/month.

Monitoring protocol

Serum lithium: 7 days after any dose change, then 3-monthly when stable. Target: 0.6–0.8 mmol/L for maintenance; 0.8–1.0 mmol/L for acute episodes (sample 12 hours post-dose).

eGFR, electrolytes, calcium, TSH, weight: 3-monthly for the first year, then 6–12 monthly. Long-term lithium effects include CKD (~20% over 20 years, though severity has been revised downward with careful monitoring), hypothyroidism (~20%), hyperparathyroidism, and weight gain.

ECG annually; also at initiation for PR/QRS/QTc baseline.

Lithium toxicity — the critical drug interactions

Toxicity occurs above 1.5 mmol/L. Severe toxicity above 2.5 mmol/L causes seizures and coma; mortality risk. Early signs: coarse tremor, nausea, diarrhoea, confusion, ataxia, and dysarthria.

Drugs that raise lithium levels (avoid or monitor very carefully):

• NSAIDs (ibuprofen, naproxen, diclofenac, celecoxib) — reduce renal lithium clearance.
• ACE inhibitors and ARBs — reduce renal clearance.
• Thiazide diuretics — sodium depletion drives lithium retention.
• COX-2 inhibitors.

Dehydration from illness, heat, or exercise also raises levels. Counsel patients explicitly: if unwell, febrile, or unable to drink fluids — hold lithium and present for a serum level. Never take ibuprofen for a fever or pain while on lithium — use paracetamol instead.

If toxicity suspected: stop lithium, hydrate urgently, urgent serum lithium level, specialist review. Haemodialysis for severe toxicity.

Other mood stabilisers

Valproate (sodium valproate, Epilim): Effective for acute mania and maintenance — but per TGA Pregnancy Prevention Program, it may only be used in women of childbearing potential if no adequate alternative exists and strict PPP criteria are documented at every prescription (effective contraception, pregnancy test, annual counselling). PBS general schedule; specific TGA/PBS conditions apply for this population.

Lamotrigine: Particularly effective for depression prevention in bipolar. Must be titrated slowly (risk of Stevens-Johnson syndrome with rapid dose escalation). PBS Authority Required for bipolar disorder.

Atypical antipsychotics: Quetiapine, lurasidone, olanzapine — indicated for acute mania and bipolar depression. PBS Authority Required for bipolar-specific criteria. Metabolic monitoring (weight, blood pressure, glucose, lipids 6-monthly) is mandatory given metabolic syndrome risk.

C. Managing bipolar depression safely

Bipolar depression is the dominant burden in most patients’ lives — more time in depression than mania. The management challenge is treating depression without triggering a switch to mania.

Per eTG Psychotropic and AMH: quetiapine, lurasidone, olanzapine-fluoxetine combination, and lamotrigine are first-line for bipolar depression.

The antidepressant controversy: The STEP-BD trial (Sachs NEJM 2007) found that adding paroxetine or bupropion to a mood stabiliser provided no benefit over mood stabiliser alone for bipolar depression, with comparable switch rates. Subsequent evidence shows substantial switch and rapid-cycling risk, particularly in Bipolar I. The RANZCP 2020 CPG advises caution: avoid antidepressant as monotherapy; avoid in Bipolar I without robust mood stabiliser cover; avoid in rapid cycling or mixed features. If used in Bipolar II under mood stabiliser cover — cease immediately if mania, hypomania, or mixed features emerge.

Psychological therapies — psychoeducation (the single most cost-effective intervention), family-focused therapy, CBT, and Interpersonal Social Rhythm Therapy (IPSRT — stabilises sleep and activity rhythms) — are adjuncts to pharmacotherapy, not substitutes.

Sleep is therapeutic: Sleep deprivation is a recognised mania trigger. A fixed sleep-wake schedule, even on weekends, is a cornerstone non-pharmacological intervention. Counsel strongly.

D. Australian operations

PBS authority codes: Lithium carbonate (Quilonum SR, Lithicarb) general schedule. Sodium valproate (Epilim, Valpro) general schedule with TGA Pregnancy Prevention Program documentation for women of childbearing potential. Lamotrigine Authority Required (Streamlined) bipolar indication. Atypical antipsychotics (olanzapine, quetiapine, risperidone, aripiprazole, lurasidone, asenapine) Authority Required for bipolar-specific PBS criteria. Long-acting injectable antipsychotics Authority Required for refractory or non-adherent patients.

MBS items: Mental Health Care Plan (2715 for ≥20 min, 2717 for ≥40 min, review 2712) — applicable to bipolar; note the 1 November 2025 rule: MHCP payable only when patient is MyMedicare-registered or GP is the usual GP. Better Access psychology (80100–80170) up to 10 individual sessions annually — CBT, IPSRT, family-focused therapy. GPCCMP (965/967) for chronic bipolar with CV or metabolic comorbidity. Lithium level pathology (MBS 66711). ECG (11700) annual. Telehealth items 91890 (video), 91891 (phone) — existing-relationship rule applies.

NDIS: Severe bipolar disorder with psychosocial disability can meet NDIS eligibility criteria — access via Local Area Coordinator.

Real-time prescription monitoring (RTPM): Benzodiazepines for agitation management — mandatory SafeScript/QScript/RTPM check per state before prescribing.

Medico-legal: Fitness to drive — acute bipolar episode in past 6 months or persistent functional impairment requires review per Austroads. Firearms licence — bipolar diagnosis affects licensing; state legislation varies. Document all fitness-to-drive discussions and clinical status objectively.

E. Special populations

Pregnancy: Perinatal psychiatry co-management is essential. Valproate is contraindicated in pregnancy (neural tube defects ~10%; neurodevelopmental impairment ~30–40%). Lithium carries a small Ebstein’s cardiac anomaly risk in the first trimester — high-resolution fetal echocardiogram at 18 weeks. Lamotrigine is generally safer in pregnancy. Quetiapine and olanzapine are reasonable with metabolic monitoring. Postpartum period carries the highest relapse risk in the lifetime of bipolar disorder — close monitoring and prompt medication reinstatement if medications were discontinued during pregnancy.

Young people (15–25 years): The peak onset decade. Bipolar in young people is often misdiagnosed as ADHD, borderline personality, substance-induced mood disorder, or unipolar depression. Specialist input is always required. Avoid valproate in female adolescents.

Elderly: Lithium toxicity risk is higher due to reduced eGFR, polypharmacy, and dehydration susceptibility. Lower serum targets (0.4–0.6 mmol/L) may be appropriate in well-stabilised older adults with CKD risk — specialist guidance. Atypical antipsychotics carry increased stroke and mortality risk in dementia — bipolar in older adults requires careful specialist input.

Comorbid substance use: Common and bidirectional — cannabis and stimulants are recognised mania triggers. Integrated dual-diagnosis treatment outperforms sequential treatment. Cannabis (particularly high-THC products) should be strongly discouraged in all bipolar patients.

When to escalate

Urgent ED or mental health emergency team:

• Acute mania with psychosis, severe agitation, or risk to self or others — may require involuntary admission under state Mental Health Act.
• Severe bipolar depression with suicidality.
• Suspected lithium toxicity.
• Postpartum mania or psychosis — mother-baby unit referral.

Same-week psychiatry referral:

• First suspected bipolar episode (mania, hypomania, or antidepressant-induced switch).
• Pregnancy planning in a patient on a teratogenic mood stabiliser.
• Treatment-resistant depression in a patient already on a mood stabiliser.
• Mixed features or rapid cycling.

Crisis lines: Lifeline 13 11 14; Beyond Blue 1300 22 4636; state mental health lines (public sector crisis teams available 24 hours).

What this article is and is not

This is general health information drawn from current Australian mental health guidelines — RANZCP 2020 Mood Disorders CPG, eTG Psychotropic, AMH, RACGP — and international guidelines (NICE CG185) where Australian guidance is silent. It is not personal medical advice and does not create a doctor–patient relationship. Diagnosis, medication initiation, and monitoring protocols are determined with your GP and psychiatrist.

For consumer-friendly resources: HealthDirect — Bipolar disorder, Black Dog Institute, Beyond Blue, SANE Australia.

---

Sources cited

1. RANZCP — 2020 Mood Disorders Clinical Practice Guideline
2. Therapeutic Guidelines (eTG) — Psychotropic
3. Australian Medicines Handbook (AMH)
4. RACGP
5. TGA — sodium valproate Pregnancy Prevention Program
6. NICE CG185 — Bipolar disorder: assessment and management
7. HealthDirect — Bipolar disorder
8. Black Dog Institute — Bipolar disorder
9. Beyond Blue
10. SANE Australia
11. Cipriani A et al — Lithium and suicide prevention (BMJ 2013)
12. BALANCE Collaborative Group — Lithium vs valproate (Lancet 2010)
13. Sachs GS et al — STEP-BD antidepressant trial (NEJM 2007)
14. Malhi GS et al — Mood disorders summary (MJA 2018)