If a trial with one of these medications is not successful, referral to a psychiatric provider for further evaluation is recommended. If medication is not effective or not tolerated in managing bipolar disorder, electroconvulsive therapy may be an option (Kennedy, 2008; Sajatovic, 2002b). Consultation needs to be considered, as management of bipolar disorder is complicated (Hoblyn, 2004). Close collaboration between the primary care practitioner and psychiatric provider is essential (Hoblyn, 2004). If the patient is not agreeable to the referral, the management guidelines in Figure 2 are recommended.