The Waco Guide

High
risk
Yes
Discontinue
antidepressants
Yes
No
More severe
symptoms
Less severe
symptomsAdequate
response
Inadequate
response
Inadequate response after
two first-choice trials
Partial response to
first-choice treatment
No response to
first-choice treatment
No
Yes
No
No
Partial
response
Inadequate
response
Inadequate response after
two First Choice trials
Partial response to
First Choice treatment
two months of no manic symptoms
No response to
First Choice treatment
Yes
No / partial response
Depressive
symptoms
Bipolar Disorder
Evaluate for SI/HI,
aggression, psychosis
ER for hospitalization
assessment
Evaluate symptoms
Maintenance therapy indicated
in majority of patients with Bipolar
Does patient have acute mania
or history of recent / severe mania? Manic / mixed / rapid cycling
Successfully treated
in past?
Restart prior
treatment regimen
First Choice
(SOR A)
Aripiprazole
Cariprazine
Olanzapine
Risperidone
Aripiprazole
Cariprazine
Quetiapine
Ziprasidone
Asenapine
Consider adding
benzodiazepine (e.g. clonazepam)
for sleep / agitation / severe anxiety
Maintenance/Relapse prevention
Evaluate for depressive symptoms
Successful control of
symptoms
Maintenance
relapse prevention:
use previously effective treatment
at lowest effective dose
(SOR B)
Second trial of other
atypical antipsychotic
Second Choice
(SOR B)
Augment with mood
stabilizer (lower dosing
may be effective)
1. Lithium 2. Valproate 3. Carbamazepine
Switch to mood
stabilizer
1. Lithium 2. Valproate 3. Carbamazepine
Aripiprazole
Olanzapine
Risperidone
Cariprazine
Depressed
Successfully
treated in the past?
Restart prior
treatment regimen
Is patient currently taking
atypical antipsychotic for mania?
First Choice
(SOR A)
Lamotrigine
Augmentation
with alternate class
First Choice agent
Atypical
Antipsychotic
1. Lurasidone
(SOR A)
titrate slowly; watch for emerging
manic symptoms; uncommon
cases will need mood stabilizer
3. Quetiapine
4. Olanzapine
+ Fluoxetine
2. Cariprazine
Second trial of
First Choice treatment
Second choice
(SOR B)
Augment with mood
stabilizer
(lower dosing
may be effective)
1. Lithium
Depression
symptoms persist
Cautious introduction of lowest manufactured dose of antidepressant
(very slow titration; must be taking antipsychotic / mood stabilizer)
(SOR C)
2. Valproate 3. Carbamazepine
Switch to mood stabilizer
1. Lithium 2. Valproate 3. Carbamazepine
1. Add Lamotrigine
2. Change to Cariprazine
3. Change to Quetiapine
4. Change to Olanzapine + Fluoxetine
(at anti-manic doses)

If patient is high risk for SI/HI, aggression, or psychosis, send to ER for hospitalization assessment.

How is the patient currently presenting?