The management of individuals with bipolar disorder: a review of the evidence and its integration into clinical practice.
Bipolar disorder is a common, debilitating, chronic illness that emerges early in life and has serious consequences such as long-term unemployment and suicide. It confers considerable functional disability to the individual, their family and society as a whole and yet it is often undetected, misdiagnosed and treated poorly. In the past decade, many new treatment strategies have been trialled in the management of bipolar disorder with variable success. The emerging evidence, for pharmacological agents in particular, is promising but when considered alone does not directly translate to real-world clinical populations of bipolar disorder. Data from drug trials are largely based on findings that identify differences between groups determined in a time-limited manner, whereas clinical management concerns the treatment of individuals over the life-long course of the illness. Considering the findings in the context of the individual and their particular needs perhaps best bridges the gap between the evidence from research studies and their application in clinical practice. Specifically, only lithium and valproate have moderate or strong evidence for use across all three phases of bipolar disorder. Anticonvulsants, such as lamotrigine, have strong evidence in maintenance; whereas antipsychotics largely have strong evidence in acute mania, with the exception of quetiapine, which has strong evidence in bipolar depression. Maintenance data for antipsychotics is emerging but at present remains weak. Combinations have strong evidence in acute phases of illness but maintenance data is urgently needed. Conventional antidepressants only have weak evidence in bipolar depression and do not have a role in maintenance therapy. Therefore, this paper summarizes the efficacy data for treating bipolar disorder and also applies clinical considerations to these data when formulating recommendations for the management of bipolar disorder.
Malhi
Gin S
GS
CADE Clinic, Department of Psychiatry, Royal North Shore Hospital, Sydney, New South Wales, Australia. gmalhi@med.usyd.edu.au
Adams
Danielle
D
Cahill
Catherine M
CM
Dodd
Seetal
S
Berk
Michael
M
D000928:Antidepressive Agents / Q000191:economics / Q000627:therapeutic use; D018692:Antimanic Agents / Q000191:economics / Q000627:therapeutic use; D014150:Antipsychotic Agents / Q000191:economics / Q000627:therapeutic use*; D001714:Bipolar Disorder / Q000188:drug therapy* / Q000191:economics; D003987:Dibenzothiazepines / Q000191:economics / Q000627:therapeutic use*; D006801:Humans; D008094:Lithium / Q000191:economics / Q000627:therapeutic use; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D000069348:Quetiapine Fumarate
D000928:Antidepressive Agents; D018692:Antimanic Agents; D014150:Antipsychotic Agents; D003987:Dibenzothiazepines; D000069348:Quetiapine Fumarate; D008094:Lithium