CQAIMH - center for quality assessment and improvement in mental health



Bipolar Disorder: Use of antimanic agent in BD I with mania/hypomania, mixed, or cycling


This measure assesses the percentage of patients with BD I with mania/hypomania, mixed or cycling symptoms and behaviors who have evidence of use of a pharmacotherapy agent with antimanic properties during the first 12 weeks of treatment.

Clinical Rationale:

Goals of Acute Treatment: Mania or Mixed Episodes

  • If present, a rapid response to agitation, aggression and impulsivity is desired (1)
  • Remission of symptoms with a return to usual levels of psychosocial functioning (1)

Initial Treatment Considerations

  • Treatment selection is dependent on illness severity, associated clinical features such as rapid cycling or psychosis, and patient preference (1)
  • Treatment choice should also consider patient history, potential side effects and individual therapeutic response to specific pharmacotherapy agents (2)

Initial Treatment Recommendations

  • Refer to published guidelines for 1st stage, 2nd stage, etc. detailed recommendations
  • Guidelines suggest lithium or valproate (divalproex/divalproex sodium/valproate sodium/valproic acid) alone or in combination with an antipsychotic;  Alternatives to lithium or valproate may include carbamazepine (1,2,3) 
  • It is noted that typical antipsychotics are associated with significant acute neurologic side effect risks (extrapyradmidal) and long-term risk of tardive dyskinesia (1,2,3)
  • Clozapine has been noted as an effective antimanic therapy in treatment-resistant bipolar disorder; however, it is recommended with caution due to monitoring and safety concerns (2)

Denominator Population:

Patients with Bipolar I Disorder episodes with

  • Manic/hypomanic symptoms or behaviors
  • Mixed symptoms or behaviors
  • Cycling symptoms or behaviors

Data Sources:

  • Administrative data
  • Medical Record

Numerator Population:

Patients with evidence of use of an antimanic agent during the first 12 weeks of pharmacotherapy treatment

Data Source:

  • Medical Record
  • If available, administrative data that indicates specific pharmacotherapy

Initial Case-finding Guidance:

Patients with diagnosis of Bipolar I Disorder; manic/hypomanic, mixed or cycling
ICD9CM or DSM IV TR : 296.0x; 296.1x; 296.4x; 296.6x

Specialty-specific Measure:

This measure is recommended by the STABLE National Coordinating Council as a specialty-specific measure for psychiatry as the denominator requires specific documentation of diagnostic information indicating Bipolar I Disorder and the symptoms, behaviors, or episodes that are being addressed.


  1. Practice Guideline for the Treatment of Patients with Bipolar Disorder (2002 Revision);  American Psychiatric Association; Am J Psychiatry 159:4, April 2002 Supplement;     Also, Guideline Watch (2006) Update to the above guidelines, Hirschfeld R, American Psychiatric Association, 2006
  2. Suppes T, Dennehy E, Hirschfeld ,; Altshuler L, Bowden D, Calabrese J, Ketter T, Sachs G, Swann A, The Texas Implementation of Medication Algorithms: Update to the Algorithms for Treatment of Bipolar I Disorder, J Clin Psychiatry 2005; 66:870-886
  3. Keck PE, Perlis R, Otto M; Carpenter D, Ross R, Docherty J, Treatment of Bipolar Disorder 2004; The Expert Consensus Guideline Series, Postgraduate Medicine – A Special Report, December 2004

Copyright 2007 by the Center for Quality Assessment and Improvement in Mental Health