From Clinical guidelines — Diagnosis and treatment manual › Chapter 11: Mental disorders in adults · Médecins Sans Frontières, Current online edition (updated July 2022)
MSF clinical guidance on pharmacological management of manic and depressive episodes in bipolar disorder for resource-limited settings.
- Issuer
- Médecins Sans Frontières
- Edition
- Current online edition (updated July 2022)
- Audience
- Physicians trained in mental health working in resource-limited settings
- Evidence
- Expert consensus
- Reviewed
- 22 Oct 2026 · GMJ
What this guideline says
GMJ summary
This MSF clinical guideline section addresses the diagnosis and pharmacological management of bipolar disorder, characterised by alternating manic and depressive episodes separated by normal periods. Episodes of mania present with elation, euphoria, hyperactivity, insomnia, grandiose ideas and loss of social inhibitions, whilst depressive episodes are often severe with significant suicide risk.
First-line treatment for manic episodes is haloperidol with dosing starting at 5 mg daily and titrating to a maximum of 15 mg daily, with alternatives including risperidone (up to 6 mg daily) or olanzapine (up to 20 mg daily). If symptoms persist after 2 weeks on maximum tolerated doses of 2 different antipsychotics, a mood stabiliser should be added: valproic acid (titrated to 500 mg twice daily) or carbamazepine (titrated to 600 mg daily, maximum 1200 mg daily). Treatment should continue for at least 8 weeks after complete remission.
Long-term treatment continues with the medication that achieved remission. Valproic acid is not recommended in women of childbearing age; carbamazepine should be used instead. Treatment initiation can be by a physician trained in mental health, but specialist consultation should be arranged as soon as possible.
Key points
For clinicians — doses and thresholds as stated in the guideline
- First-line treatment for manic episodes: haloperidol PO 5 mg once daily for 3 days, then 7.5 mg for one week; increase by 2.5 mg increments weekly to maximum 15 mg daily if needed
- Alternative antipsychotics: risperidone 2 mg once daily (max. 6 mg daily, increase by 1 mg weekly) or olanzapine 10 mg once daily (max. 20 mg daily, increase by 5 mg weekly)
- Add mood stabiliser if symptoms do not resolve after 2 weeks at maximum tolerated dose of 2 different antipsychotics: valproic acid titrated to 500 mg twice daily (max. 1000 mg twice daily) or carbamazepine titrated to 600 mg daily (max. 1200 mg daily)
- Diazepam 5 to 10 mg daily can be added during the first 2 to 3 weeks of treatment for acute mania
- Continue treatment for at least 8 weeks after complete remission of symptoms before considering discontinuation
- Valproic acid is not recommended in women of childbearing age; use carbamazepine instead
- If manic episode occurs while on antidepressants, immediately stop antidepressants and treat the mania—this indicates bipolar disorder
- Long-term treatment continues with the antipsychotic, mood stabiliser, or combination that achieved remission
Pharmacological treatment protocols for manic episodes
Table extracted from the guideline
| Medication | Week 1 | Week 2 | Week 3 | Maximum dose |
|---|---|---|---|---|
| Haloperidol (first-line) | 5 mg once daily (Days 1-3), then 7.5 mg once daily | Increase by 2.5 mg if needed | Continue titration by 2.5 mg weekly | 15 mg daily |
| Risperidone (alternative) | 2 mg once daily | Increase by 1 mg if needed | Continue titration by 1 mg weekly | 6 mg daily |
| Olanzapine (alternative) | 10 mg once daily (Days 1-3) | Increase by 5 mg if needed | Continue titration by 5 mg weekly | 20 mg daily |
| Valproic acid (mood stabiliser) | 200 mg twice daily | 400 mg twice daily | 500 mg twice daily | 1000 mg twice daily |
| Carbamazepine (mood stabiliser) | 100 mg twice daily | 200 mg twice daily | 200 mg three times daily | 1200 mg daily |
Source: Médecins Sans Frontières, Bipolar disorder — MSF Clinical guidelines. Reproduced in summary form.
From the guideline
Verbatim
“If symptoms do not resolve after 2 weeks of antipsychotic treatment at maximum tolerated dose (and 2 different antipsychotics have been tried), add a mood stabiliser”
Editor’s perspective
Why this matters for Georgia and the region
Prof. Giorgi Pkhakadze, MD, MPH, PhD
Editor-in-Chief, Georgian Medical Journal · Chair, Public Health Institute of Georgia · WHO consultant, health and migration
As Editor-in-Chief of GMJ and Chair of the Public Health Institute, I recognise this MSF guideline addresses a critical gap in Georgia's mental health services, where bipolar disorder often goes unrecognised or undertreated in primary care. The stepwise pharmacological protocols using essential medicines—haloperidol, carbamazepine—align well with our national formulary and can be implemented by trained general practitioners in regions lacking psychiatric specialists. I would particularly stress to Georgian clinicians the absolute contraindication of valproic acid in women of childbearing age and the need for immediate specialist referral when switching to carbamazepine, given our experience with teratogenic medication risks. The realistic implementation challenge for Georgia is ensuring adequate training of primary care physicians in mental health assessment and establishing reliable referral pathways to the limited number of psychiatric specialists, particularly outside Tbilisi, whilst ensuring consistent availability of both first-line and alternative antipsychotics in regional pharmacies.
ORCID 0000-0001-7609-4515 · Perspective written for the GMJ Guidelines Library, 22 Oct 2026
Applicability
Georgia and the South Caucasus
This guideline is directly relevant for mental health services in Georgia and the South Caucasus, where access to psychiatric specialists remains limited, particularly in rural areas. The stepwise pharmacological approach using essential medicines on national formularies (haloperidol, carbamazepine) suits resource-constrained primary care settings. National mental health programmes in the region would need to ensure availability of alternative antipsychotics (risperidone, olanzapine) and establish clear referral pathways to specialists for long-term management. The emphasis on avoiding valproic acid in women of childbearing age aligns with international teratogenicity concerns and should be incorporated into national prescribing protocols. Implementation would require training of primary care physicians in mental health and establishing monitoring systems for long-term antipsychotic and mood stabiliser therapy.
Questions this guideline answers
Quick answers
When should I add a mood stabiliser to antipsychotic treatment for mania?
Add a mood stabiliser (valproic acid or carbamazepine) if symptoms do not resolve after 2 weeks of antipsychotic treatment at maximum tolerated dose and 2 different antipsychotics have been tried.
How long should treatment continue after a manic episode resolves?
Continue treatment for at least 8 weeks after complete remission of symptoms. Then assess with the patient the benefits and risks of pursuing long-term treatment. If discontinuing, stop medication gradually whilst monitoring for possible relapse.
What should I do if a patient on antidepressants develops a manic episode?
Immediately stop the antidepressants and treat the manic episode with an antipsychotic. An episode of mania whilst on antidepressants is indicative of bipolar disorder.
Can I prescribe valproic acid to a woman of childbearing age with bipolar disorder?
No, valproic acid is not recommended in women of childbearing age due to teratogenicity. Use carbamazepine instead. If a woman is already taking valproic acid, switch to carbamazepine by gradually decreasing valproic acid over 2 weeks whilst starting carbamazepine. If pregnancy occurs or is planned, contact a specialist urgently to re-evaluate treatment.
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Quality & accreditation
Same guideline
- Chronic psychoses — MSF Clinical guidelinesChapter 11: Mental disorders in adults
- Psychotic disorders — MSF Clinical guidelinesChapter 11: Mental disorders in adults
- Depression — MSF Clinical guidelinesChapter 11: Mental disorders in adults
- Post-traumatic stress disorder — MSF Clinical guidelinesChapter 11: Mental disorders in adults
- Acute confusional state (delirium) — MSF Clinical guidelinesChapter 11: Mental disorders in adults
- Agitation — MSF Clinical guidelinesChapter 11: Mental disorders in adults
- Issuer
- Médecins Sans Frontières
- Guideline
- Clinical guidelines — Diagnosis and treatment manual
- Chapter
- Chapter 11: Mental disorders in adults
- Type
- Clinical guideline (chapter)
- Edition
- Current online edition (updated July 2022)
- Status
- Current
- Published
- 2026-10-14
- Scope
- Diagnosis and pharmacological management of bipolar disorder in adults
- Audience
- Physicians trained in mental health working in resource-limited settings
- Evidence
- Expert consensus
- Record history
- Created 22 Oct 2026 · updated 22 Oct 2026 · next check Apr 2027
Médecins Sans Frontières. Bipolar disorder. In: Clinical guidelines — Diagnosis and treatment manual [Internet]. Paris: MSF; 2022 [updated 2022 Jul; cited 2026 Oct 14]. Available from: https://medicalguidelines.msf.org/en/viewport/CG/english/bipolar-disorder-23537021.htmlGMJ Guidelines Library records are original summaries written by the GMJ editorial team from the issuer’s published document and reviewed by a physician. They do not replace the full guideline. The document is the copyright of its issuer and is linked, not hosted. Spotted an error or a newer edition? Tell the Guidelines Desk.
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