Special review article
Treatment guidelines for bipolar disorder: A critical review

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Abstract

Introduction

The development of treatment guidelines emerged as an important element so as to standardize treatment and to provide clinicians with algorithms, which would be able to carry research findings to the everyday clinical practice.

Material and method

The MEDLINE was searched with the combination of each one of the key words ‘mania’, ‘manic’, ‘bipolar’, ‘manic-depression’, ‘manic-depressive’ with ‘treatment guidelines’.

Results

The search was updated until March 1st, 2004 and returned 224 articles. Twenty-seven papers concerning the publication of treatment algorithms were traced.

Discussion

Despite supposedly being evidence-based, guidelines for the treatment of bipolar disorder vary significantly across committees or working groups. Overall, however, at the first stage of the mania/hypomania algorithm, monotherapy with lithium, divalproex sodium or olanzapine is generally recommended. At latter stages combination therapy is strongly recommended. It is clearly stated that in bipolar depression antidepressants should be used only in combination with antimanic agents in order to avoid switching of phases. During the maintenance phase all patients should receive antimanic agents, while some may need the addition of antidepressants. The most recent guidelines emphasize the use of atypical antipsychotics for mania and lamotrigine for depression. The main problem with guidelines is that they are rapidly outdated and that the evidence base relies mainly on registration monotherapy trials that hardly reflect treatment in routine clinical conditions.

Conclusion

Treatment guidelines may be useful to avoid non-evidence-based treatment decisions, but they are quickly out-of-date and may not fully apply to the clinical setting. The more recent guidelines point the value of atypical antipsychotics, lithium, and valproate in the treatment of mania; the role of lithium, lamotrigine, and olanzapine as options for maintenance therapy; and the scarcity of options for the treatment of bipolar depression. Psychoeducation is also supported by most guidelines as an adjunctive treatment.

Introduction

The development of treatment guidelines emerged as an important element so as to standardize treatment and to provide clinicians with algorithms, which would be able to carry research findings to the everyday clinical practice, by organizing information from diverse sources into an easily accessible format.

The aim of the current study is to review contemporary available treatment guidelines for bipolar disorder. Although several issues are relevant (adolescence, old age, pregnancy, comorbid conditions) this article focuses on the treatment guidelines concerning otherwise physically healthy and physiologically stable adults suffering from bipolar disorders.

Section snippets

Material and method

The MEDLINE was searched with the combination of each one of the key words ‘mania’, ‘manic’, ‘bipolar’, ‘manic-depression’, ‘manic-depressive’ with ‘treatment guidelines’ and ‘treatment algorithms’. The search returned 224 articles. The search was updated until March 1st, 2004. Finally the review process based on the titles and abstracts selected 84 of them for further study. Among them there were 23 papers concerning structured treatment algorithms proposed by official panels (1997, AACAP, 1997

Results

American Psychiatric Association treatment guidelines: The first detailed operational treatment guidelines concerning bipolar disorder published, were those of the American Psychiatric Association (American Psychiatric Association, 1994, American Psychiatric Association, 1995, American Psychiatric Association, 2002). Their development was based on expert opinion and reviewers which evaluated all available evidence. The first version was published in 1994. In that version, five types of

Discussion

Bipolar illness has a complex clinical picture and an even more complex treatment. There are more than one traditional clinical approach to treatment with a traditional difference between academic authorities in Europe (in favor of the use of antipsychotics and antidepressants) and the US (in favor of so-called mood stabilizers).

The various treatment guidelines generally seem to have a common starting point, best described by the 1994 APA guidelines (American Psychiatric Association, 1994). But

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