Principles of managing rapid cycling bipolar disorder in adults and young people

Patients with 4 or more mood episodes in a 12-month period have rapid cycling bipolar disorder. It the most difficult to treat of all bipolar disorder presentations, so management should be supervised by a psychiatrist.

In some patients, rapid cycling bipolar disorder is precipitated by antidepressant use, hypothyroidism, problem substance use (eg alcohol, illicit drugs, excessive caffeine consumption) or nonprescription medicines, such as diet or weight-loss drugs. If a precipitant is identified, manage the condition or gradually withdraw the substance. Precipitous withdrawal of a substance can provoke a mood switch.

Treatment of rapid cycling bipolar disorder aims to stabilise the mood (ie prevent rapid cycling) with prophylactic therapy, rather than initiating or adjusting treatment of the current mood episode. No treatment has strong evidence in rapid cycling bipolar disorder but there is limited evidence for sodium valproate or carbamazepine monotherapy, so either drug may be trialled as initial treatment. If there has been no improvement after 3 to 4 months, trial the alternate drug. See Prophylaxis of bipolar disorder for drug regimens.

If symptoms are severe, electroconvulsive therapy (ECT) may be considered.