Evidence Based Guidelines Bipolar Disorder Treatment

Evidence Based Guidelines for

Bipolar Disorder Treatment: 

Revised Third Edition Recommendations From the British Association for Psychopharmacology

 

(A) ACUTE MANIC EPISODES

(1) Patient NOT on Long Term Treatment:

 

  • Haloperidol, Olanzapine, Risperidone & Quetiapine (effective in short term reduction of symptoms).
  • Valproate: alternative treatment option (but use with caution in women of child bearing age)
  • In Agitated Patient: Dopamine antagonists/partial agonists and GABA modulators (benzodiazepines)- in lowest doses necessary.
  • Antidepressants should be tapered and discontinued.
(2) Patient ON Long Term Treatment:

 

  • Consider highest tolerated dose of current medication.
  • For Lithium: 0.8-1 nmol/L may be more effective.
  • With Lithium: Consider adding dopamine antagonist or partial agonist, or valproate.
  • Consider Clozapine in more refractory cases.
  • ECT may be considered for: severe treatment resistance, patient preference and severe mania during pregnancy.

 

(B) ACUTE DEPRESSIVE EPISODES

(1) Patient NOT on Long Term Treatment:

    • Quetiapine, Lurasidone or Olanzapine.

 

    • Antidepressants not adequately studies: Only Fluoxetine + Olanzapine has support.

 

    • Consider Lamotrigine (usually as an addition to agents preventing recurrence of mania).

 

    • Consider ECT: high suicidal risk, treatment resistance, psychosis, severe depression during pregnancy or life-threatening condition.

 

  • Consider family-focused, cognitive behaviour therapy or interpersonal rhythm therapy as an additional treatment.

(2) Patient ON Long Term Treatment:

  • Consider highest tolerated dose of current medication.

(3) Note on Antidepressants:

    • Antidepressant are unlikely to induce mania when used in combination with a drug for mania.

 

    • Consider Discontinuation of antidepressants after as little as 12 weeks in remission.

 

  • Longer treatment with antidepressants is justified if patients relapse on their withdrawal.

 

(C) LONG TERM TREATMENT

  • Offer enhanced psychoeducation, motivational and family support, especially in the early stages of illness to promote behavior change and adherence to medication.
  • Preferred strategy is for continuous rather than intermittent treatment with medications.

(1) Choice of Long Term Medications:

 

  • Lithium> Valproate> Olanzapine > Lamotrigine> Quetiapine> Carbamazepine.
  • Consider lithium as initial monotherapy
  • Lamotrigine and quetiapine may be considered as monotherapy in bipolar II disorder.
(2) If Patient Fails to Respond to Monotherapy and Continues to Experience Subthreshold Depressive Symptoms or Relapses:

 

  • In mania: combine two predominantly anti-manic agents (e.g. lithium, valproate, dopamine antagonist or a dopamine partial agonist)
  • In bipolar depression: Combination of lithium, lamotrigine, quetiapine, lurasidone or olanzapine may be more appropriate.
  • Consider continuation of clozapine if effective in refractory mania.
  • Maintenance ECT may be considered for patients who respond to ECT during an acute episode but respond poorly to all oral agents.
  • Consider adjunctive psychotherapy to address subthreshold symptoms
 (3) Discontinuation of Long Term Medications:

 

  • Following Discontinuation the risk of relapse remains, even after years of sustained remission.
  • Medications should normally be tapered over at least 4 weeks and preferably longer.
  • Early relapse to mania is an early risk of abrupt lithium discontinuation.

 

(D) IN CHILDREN & YOUNG PEOPLE

 (1) For Mania:

    • Consider Aripiprazole as first line.

 

  • Some evidence that olanzapine, quetiapine, and risperidone are efficacious in adolescents.

(2) For Bipolar Depression:

 

  • Same recommendations as adults above.

 

SourceJournal of Psychopharmacology 2016, Vol. 30(6) 495–553

 

Please do post your questions or comments below. 


Dr. Harvinder Singh, M.D. (Admin)


Enroll in our online course to have access to all important clinically relevant psychiatry topics in one place.


Related Articles