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Bipolar disorder is a serious mental illness presenting with exacerbations and remissions. Relapses should be minimized and that is achieved by preventive treatments. Developing easily applicable and reachable algorithms by incorporating data coming from various sources, implementing research findings in daily practice, and providing standardized treatment choices are all important. Many guidelines have been published for bipolar disorders so far.
American Psychiatric Association (APA) Guidelines: This guidelines recommend preventive treatment after one manic episode. The main goals of treatment are to prevent relapse, resolve subclinical residual symptoms, and to decrease suicide risk. Lithium and valproate are primary agents, as they have the most evidence of efficacy. Their alternatives lamotrigine, carbamezapine, and oxscarbamezapine are secondary agents. In general continuation of preventive medications used during acute management is first choice during maintenance treatment. ECT can be used as a maintenance treatment. Antipsychotics should be discontinued if there is no persistent psychotic symptoms.
Cognitive behavioral, interpersonal, and psychodynamic therapies can be used in addition to medications. Psychoeducation is reported to be beneficial. Keeping lithium levels between 0.8-1.0 mEg/L during maintenance phase were mentioned to be more effective. In this guideline generally accepted treatments were mentioned as non-definite recommendations.
Texas Medication Algorithm: Acute phase doses should be continued at least 3 months. All patients are recommended to receive antimanic medications during maintenance phase, if necessary some can receive low dose antidepressants. Lifelong maintenance treatment is recomended if patients had 2 manic episodes or one manic episode with positive family history, or the acute episode was very severe. This group of authors think antimanic medications are the core of the treatment and they emphasize depression less. In addition they recommend ECT and tricyclics, which were demonsterated to be effective, in final stages due to side effects and patient preferences.
Expert Opinion Series on Medication Treatment in Bipolar Disorder: They recommend continuation of treatment, which was effective in acute phase except in divalproex monotherapy and predominantly depressive cases. They suggest adding lithium in those cases. They recommend that antipsychotics should be stopped during maintenance phase, but some patients may need to continue taking antipsychotics. In that case, one of olanzapine, risperidone, or quetiapine can be chosen. Against manic episode risk they suggest to increase the dose of mood stabilizer, add another mood stabilizer, and try additional treatments afterwards. This algorithm has many structural features and is very detailed.
British Psychopharmacology Association Guidelines: According to this guideline lithium is the first choice and second choice medications include valproate, olanzapine, carbamazepine, oxcarbazepine, and lamotrigine. Treatment resistant cases can be treated with medication combinations, clozapine, or ECT.
World Federation of Biological Psychiatry Associations Biological Treatments in Bipolar Disorders: It is recommended to use combination of antidepressant and mood stabilizers after depressive episodes. After manic episodes lithium, anticonvulsants, or antipsyhotics are suggested. When first line treatments fail, trying combinations of first line agents is recommended. It seems to be the most balanced guideline published so far. While they avoid newly discovered treatments , they support use of antipsychotics and antidepressants with caution.
Canmat: Once the patient becomes asymptomatic, it is suggested to discontinue all medications other than mood stabilizers and to continue maintenance treatment for 6-12 months after a single episode of illness. This guideline has similarities with APA guideline and recommends lifelong maintenance treatment in patients with recurrent episodes or positive family history.
Australia and New Zealand Bipolar Disorder Treatment Algorithm: It suggests to avoid antidepressant use during maintenance phase after depressive episodes due to precipitating mania and rapid cycling, but recommends mood stabilizer and antidepressant use in cases with recurrent depressive episodes. The duration of treatment after first manic episode is 6 months and lithium, valproate, carbamazepine, or lamotrigine are listed as recommended medications to prevent recurrent episodes.
NICE Treatment Guidelines: They recommend at least 2 year of maintenance treatment after 1 episode. Long term preventive treatment should be considered in the following cases: One manic episode with prominent risk factors and negative results and bipolar II cases with significant functional loss, suicide risk, and frequent recurrent episodes. Lithium, olanzapine, or valproate can be used in long term maintenance treatment, but valproate should not be used in women with pregnancy potential.
When monotherapy with one of those is not adequate, one of three can be added as a second agent or monotherapy can be tried with a different agent. Possible combinations are lithium-valproate, lithium-olanzapine, or valproate-olanzapine.
Turkish Psychiatry Association Guidelines: Maintenance treatment is suggested in general after second episode, but it can be started in cases with risk factors. If a mood stabilizer was initiated during acute phase, it should be continued in maintenance phase, if not, then one should be started. When a mood stabilizer will be chosen for maintenance phase, it should be lithium. After second episode, whatever the type of episode was, the same mood stabilizer should be continued if there was one. When there is not adequate response and recurrence occurs a second mood stabilizer should be added. In cases using lithium as first mood stabilizer, valproate should be given priority as the second mood stabilizer.
In conclusion, even there are similarities in many areas among guidelines, there are also different recommendations regarding treatment options. Those differences stem from complex clinical presentations of bipolar disorder and different cultural and traditional treatment approaches.
References:
1. Fountoulakis KN, Vieta E, Sanchez-Moreno J, Kaprinis SG, Goikolea JM, Kaprinis GS. Tretament guidelines for bipolar disorder: A critical review. J Affective Dis 2005; 86: 1-10.
2. Perlis RH. Use of treatment guidelines in clinical decision making in bipolar diorder: a pilot survey of clinicians. Curr Med Res Opin 2007; 23; 467-475.
3. Samalin L, Guillaume S, Auclair C, Llorca PM. J Nerv Ment Dis 2011; 199: 239-243.