A European perspective on the Canadian guidelines for bipolar disorder

Department of Psychiatry, University of Groningen, Groningen, Groningen, Netherlands
Bipolar Disorders (Impact Factor: 4.97). 02/2005; 7 Suppl 3(s3):73-6. DOI: 10.1111/j.1399-5618.2005.00221.x
Source: PubMed


Vieta E, Nolen WA, Grunze H, Licht RW, Goodwin G. A European perspective on the Canadian guidelines for bipolar disorder. Bipolar Disord 2005: 7 (Suppl. 3): 73–76. © Blackwell Munksgaard, 2005

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    • "It is likely that there are many reasons underlying the variations in guidelines, including the paucity of controlled head-to-head trials on which to base recommendations, differences in the availability of pharmacological products, and differences in personal experiences and opinions. Furthermore, variation may reflect the rapidly changing armamentarium of agents available for bipolar maintenance, which can result in guidelines becoming outdated (Vieta et al. 2005). Guidelines that are frequently updated, or that have been recently updated, will be based upon different data than those for which an update is due. "
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    ABSTRACT: The purpose of this meta-analysis was to examine the efficacy of maintenance treatments for bipolar disorder. Placebo-controlled or active comparator bipolar maintenance clinical trials of ≥6 months' duration with at least 15 patients/treatment group were identified using Medline, EMBASE,, and Cochrane databases (1993 to July 2010). The main outcome measure was relative risk for relapse for patients in remission. Twenty trials (5,364 patients) were identified. Overall, lithium and quetiapine were the most studied agents (eight and five trials, respectively). The majority of studies included patients who had previously responded to treatment for an acute episode. All interventions, with the exception of perphenazine+mood stabilizer, showed a relative risk for manic/mixed or depressive relapse below 1.0, although there was variation in the statistical significance of the findings vs. placebo. No monotherapy was associated with a significantly reduced risk for both manic/mixed and depressed relapse. Of the combination treatments, only quetiapine+lithium/divalproex, was associated with a significantly reduced risk vs. comparator (placebo+lithium/valproate) for relapse at both the manic/mixed and depressed poles of bipolar illness. Limitations for the analysis include differences in study durations and definitions of relapse. In conclusion, available maintenance therapies show considerable variation in efficacy. The efficacy of lithium and divalproex has been confirmed, but newer therapies, such as a number of atypical antipsychotics were also shown to be effective in bipolar disorder. Efficacy of all maintenance interventions needs to be balanced against the safety and tolerability profiles of individual agents.
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    ABSTRACT: Manic-depression or bipolar disorder (BD) is a multi-faceted illness with an inevitably complex treatment. This article summarizes the current status of our knowledge and practice of its treatment. It is widely accepted that lithium is moderately useful during all phases of bipolar illness and it might possess a specific effectiveness on suicidal prevention. Both first and second generation antipsychotics are widely used and the FDA has approved olanzapine, risperidone, quetiapine, ziprasidone and aripiprazole for the treatment of acute mania. These could also be useful in the treatment of bipolar depression, but only limited data exists so far to support the use of quetiapine monotherapy or the olanzapine-fluoxetine combination. Some, but not all, anticonvulsants possess a broad spectrum of effectiveness, including mixed dysphoric and rapid-cycling forms. Lamotrigine may be effective in the treatment of depression but not mania. Antidepressant use is controversial. Guidelines suggest their cautious use in combination with an antimanic agent, because they are supposed to induce switching to mania or hypomania, mixed episodes and rapid cycling. The first-line psychosocial intervention in BD is psychoeducation, followed by cognitive-behavioral therapy. Other treatment options include Electroconvulsive therapy and transcranial magnetic stimulation. There is a gap between the evidence base, which comes mostly from monotherapy trials, and clinical practice, where complex treatment regimens are the rule.
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