What are the recommended monitoring protocols for patients on mood stabilizers for bipolar disorder?

Recommended monitoring protocols for patients receiving mood stabilizers for bipolar disorder include:

• Lithium monitoring: Measure plasma lithium levels every 3 months during the first year of treatment, then every 6 months thereafter, or every 3 months for higher-risk groups such as older adults, those on interacting drugs, or with impaired renal/thyroid function. Monitor weight or BMI, urea and electrolytes including calcium, estimated glomerular filtration rate (eGFR), and thyroid function every 6 months, with more frequent checks if abnormalities or mood symptoms arise. Monitor for neurotoxicity symptoms (e.g., paraesthesia, ataxia, tremor, cognitive impairment) at every appointment. Avoid prescribing or advise caution with NSAIDs, monitoring lithium levels monthly if NSAIDs are used regularly. If lithium is stopped, reduce dose gradually over at least 4 weeks and monitor closely for relapse for 3 months after cessation ¹.
• Valproate monitoring: Valproate should not be started in people under 55 years unless two specialists independently agree no other effective treatment exists, due to reproductive risks. Females of childbearing potential must be enrolled in a pregnancy prevention programme, and males advised on contraception. Monitoring includes assessment of side effects and physical health, but specific blood test intervals are not detailed here ¹,².
• Physical health monitoring: Conduct comprehensive annual physical health reviews including weight/BMI, diet, physical activity, cardiovascular status (pulse, blood pressure), metabolic status (fasting glucose or HbA1c, lipid profile), liver function, renal and thyroid function, and calcium levels (especially for those on lithium). Manage identified cardiovascular risk factors, diabetes, obesity, and respiratory conditions accordingly. Send results to care coordinators and psychiatrists, and attempt contact if patients miss reviews ¹,².
• Mental health monitoring: Assess symptom control regularly by inquiring about mania, hypomania, and depression symptoms, and early warning signs of relapse. More frequent mental health reviews are recommended if the patient or carer expresses concerns, if there is sleep disturbance, or after significant life events. Use relapse prevention strategies including medication adherence, sleep hygiene, routine structuring, and self-monitoring ².
• Shared care and referral: Initiation of lithium and valproate should be under specialist or shared-care arrangements. Patients managed solely in primary care should be re-referred to secondary care if there is poor response, significant functional decline, intolerable side effects, comorbid substance misuse, pregnancy planning, or medication discontinuation considerations ¹,².