Establishment

Not on medication or

first-line medications

Initiate Li, DVP,

AAP, or 2-drug combination

On first-line agent

Lithium or

DVP

Add or switch to

AAP

AAP

Add or switch to Li or DVP

Replace one or both agents with other first-

line agents

2ND DRUG COMBINATION (Li

or DVP + AAP)

Replace one or both agents with other

first-line agents

Consider adding or switching to second or third-line agent or ECT

Consider adding novel or experimental agent

• MONOTHERAPY: LITHIUM, DIVALPROEX, DIVALPROEX ER, OLANZAPINEB, RISPERIDONE, QUETIAPINE, QUETIAPINE XR, ARIPIPRAZOLE, ZIPRASIDONE, ASENAPINE , PALIPERIDONE ER

• ADJUNCTIVE THERAPY WITH LITHIUM OR DIVALPROEX: RISPERIDONE, QUETIAPINE, OLANZAPINE, ARIPIPRAZOLE, ASENAPINE

• MONOTHERAPY: CARBAMAZEPIN, CARBAMAZEPINE ER, ECT, HALOPERIDOL

• COMBINATION THERAPY: LITHIUM + DIVALPROEX

• MONOTHERAPY: CHLORPROMAZINE, CLOZAPINE, OXCARBAZEPINE, TAMOXIFEN, CARIPRAZINE (NOT YET COMMERCIALLY AVAILABLE)

• COMBINATION THERAPY: LITHIUM OR DIVALPROEX + HALOPERIDOL, LITHIUM + CARBAMAZEPINE, ADJUNCTIVE TAMOXIFEN

• MONOTHERAPY: GABAPENTIN, TOPIRAMATE, LAMOTRIGINE, VERAPAMIL, TIAGABINE

• COMBINATION THERAPY: RISPERIDONE + CARBAMAZEPINE, OLANZAPINE + CARBAMAZEPINE

NB:Olanzapine: Given the

metabolic side effects, use should

be carefully monitored.