Treatment of bipolar disorder: a systematic review of available data and clinical perspectives

Abstract

This paper is a systematic review of the available data concerning the treatment of bipolar disorder: a systematic Medline search concerning treatment guidelines and clinical trials. The search for treatment guidelines returned 583 articles and 913 papers for RCTs. The search was last performed on 1 March 2008. An additional search included repositories of clinical trials and previous systematic reviews in order to trace especially older trials. The literature suggests that lithium is useful during the acute manic and the maintenance phase. Both first- and second-generation antipsychotics are efficacious in the treatment of acute mania. Quetiapine and the olanzapine-fluoxetine combination are also effective for treating bipolar depression, while olanzapine, quetiapine and aripiprazole are effective during the maintenance phase. Anticonvulsants, particularly valproate and carbamazepine have antimanic properties, whereas lamotrigine may be preferably effective in the treatment of depression but not mania. Antidepressants should always be used in combination with an antimanic agent because they were reported to induce switching to mania or hypomania, mixed episodes, and rapid cycling when given as monotherapy. The best evidence-based psychosocial interventions for bipolar disorder are group- and family-focused psychoeducation. Electroconvulsive therapy is an option for refractory patients. Although a variety of treatment options for bipolar disorder is currently available, their effectiveness is far from satisfactory, especially against bipolar depression and maintenance. Combination therapy may improve treatment outcome but it also carries the burden of more side-effects. Further research as well as the development of better guidelines and algorithms for step-by-step rational treatment are necessary.

Pharmacological treatment of depression and bipolar disorder in children and adolescents

“…An RCT of valproate in children and adolescents with bipolar-spectrum disorder who had a parent with bipolar disorder was also negative , in contrast to adult results for acute mania (Fountoulakis 2008). Several other symptoms should be present in addition to mood change and increased energy (number of symptoms not specified)…”

“…There is very little evidence to support the use of carbamazepine in children and adolescents (Consoli 2007;Smarty 2007;Carlson 2010), although there is an evidence base for adults (Fountoulakis 2008;Goodwin 2009). …”

“…Lamotrigine is approved for maintenance treatment in adults in the USA and is preferentially effective in depression (Fountoulakis 2008;Goodwin 2009). Open-label studies in adolescents suggest that lamotrigine may be effective in bipolar depression as well as controlling manic symptoms (Chang 2006;Pavuluri 2009;Biederman 2010).…”

“…Owing to the lack of a strong evidence base for treatment of bipolar disorder in children and adolescents, guidelines are largely extrapolated from the adult literature, although even this evidence base is limited (Fountoulakis 2008). As this is a rapidly changing area, clinicians need to keep abreast of the emerging literature.…”

The Future of Mental Health Care Toward an Integrative Paradigm

“…In fact there is evidence that rates of some disorders are increasing in spite of ongoing advances in biomedical psychiatry. Furthermore, recently published systematic reviews of quality double-blind placebo-controlled trials fail to show strong efficacy for widely used conventional pharmacological therapies used to treat common psychiatric disorders including major depressive disorder, bipolar disorder, schizophrenia, dementia, and others (Moller 2007;Kirsch 2008;Thase 2008;Fournier et al 2010;Fountoulakis 2008;Katzman 2009;Dixon et al 2009;Tajima et al 2009;Birks 2006) In addition to growing concerns about their lack of efficacy psychopharmacologic treatments are plagued by serious safety issues. Many widely used psychotropic drugs are associated with serious adverse effects including weight gain and increased risk of diabetes and heart disease, neurologic disorders, and sudden cardiac death, and increased suicide risk.…”