PRA CT ICE GU IDEL INE FO R TH E

Treatment of Patients With
Bipolar Disorder
Second Edition
WORK GROUP ON BIPOLAR DISORDER
Robert M.A. Hirschfeld, M.D., ChairCharles L. Bowden, M.D.
Michael J. Gitlin, M.D.
Paul E. Keck, M.D.
Trisha Suppes, M.D., Ph.D.
Michael E. Thase, M.D.
Karen D. Wagner, M.D., Ph.D.
Roy H. Perlis, M.D. (Consultant)Originally published in April 2002. This guideline is more than 5 years old and has not yet
been updated to Ensure that it reflects current knowledge and practice. In accordance withnational standards, including those of the Agency for Healthcare Research and Quality’s
National Guideline Clearinghouse (http://www.guideline.gov/), this guideline can no longer
be assumed to be current. A third edition of this guideline is in development; publication is
expected in December 2009. The November 2005 Guideline Watch associated with thisguideline provides additional information that has become available since publication of theguideline, but it is not a formal update of the guideline.

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AMERICAN PSYCHIATRIC ASSOCIATIONSTEERING COMMITTEE ON PRACTICE GUIDELINESJohn S. McIntyre, M.D.,
Chair
Sara C. Charles, M.D.,
Vice-Chair
Daniel J. Anzia, M.D.
Ian A. Cook, M.D.
Molly T. Finnerty, M.D.
Bradley R. Johnson, M.D.
James E. Nininger, M.D.
Paul Summergrad, M.D.
Sherwyn M. Woods, M.D., Ph.D.
Joel Yager, M.D.

AREA AND COMPONENT LIAISONS
Robert Pyles, M.D. (Area I)
C. Deborah Cross, M.D. (Area II)
Roger Peele, M.D. (Area III)
Daniel J. Anzia, M.D. (Area IV)
John P. D. Shemo, M.D. (Area V)
Lawrence Lurie, M.D. (Area VI)
R. Dale Walker, M.D. (Area VII)
Mary Ann Barnovitz, M.D.
Sheila Hafter Gray, M.D.
Sunil Saxena, M.D.
Tina Tonnu, M.D.

STAFF
Robert Kunkle, M.A., Senior Program Manager
Amy B. Albert, B.A., Assistant Project Manager
Laura J. Fochtmann, M.D., Medical Editor
Claudia Hart, Director, Department of Quality Improvement andPsychiatric Services
Darrel A. Regier, M.D., M.P.H., Director, Division of Research

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CONTENTS

Statement of Intent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Guide to Using This Practice Guideline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Development Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8Part A: Treatment Recommendations for Patients With Bipolar Disorder. . . . . . . . . . . . . . . . 9
I. Executive Summary of Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
A. Psychiatric Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
B. Acute Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
C. Maintenance Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
II. Formulation and Implementation of a Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
A. Psychiatric Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
B. Acute Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
C. Maintenance Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
III. Special Clinical Features Influencing the Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
A. Psychiatric Features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
B. Demographic and Psychosocial Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
C. Concurrent General Medical Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Part B: Background Information and Review of Available Evidence . . . . . . . . . . . . . . . . . . . 26
IV. Disease Definition, Natural History and Course, and Epidemiology . . . . . . . . . . . . . . . . . . . . . . . 26
A. Definition of Bipolar Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
B. Natural History and Course. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
C. Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
V. Review and Synthesis of Available Evidence. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
A. Somatic Treatments of Acute Manic and Mixed Episodes . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
B. Somatic Treatments of Acute Depressive Episodes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
C. Rapid Cycling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
D. Maintenance Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
E. Psychosocial Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
F. Somatic Therapies for Children and Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

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Part C: Future Research Needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
VI. General Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
VII. Acute Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
A. Manic and Mixed Episodes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
B. Depressive Episodes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
C. Rapid Cycling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
VIII. Maintenance Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
IX. Psychosocial Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Individuals and Organizations That Submitted Comments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

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STATEMENT OF INTENT

The American Psychiatric Association (APA) Practice Guidelines are not intended to be construed or to serve as a standard of medical care. Standards of medical care are determined on
the basis of all clinical data available for an individual patient and are subject to change as scientific knowledge and technology advance and practice patterns evolve. These parameters ofpractice should be considered guidelines only. Adherence to them will not ensure a successful
outcome for every individual, nor should they be interpreted as including all proper methodsof care or excluding other acceptable methods of care aimed at the same results. The ultimate
judgment regarding a particular clinical procedure or treatment plan must be made by the psychiatrist in light of the clinical data presented by the patient and the diagnostic and treatment
options available.
This practice guideline has been developed by psychiatrists who are in active clinical practice. In addition, some contributors are primarily involved in research or other academic
endeavors. It is possible that through such activities some contributors, including work groupmembers and reviewers, have received income related to treatments discussed in this guideline. A number of mechanisms are in place to minimize the potential for producing biased
recommendations due to conflicts of interest. Work group members are selected on the basisof their expertise and integrity. Any work group member or reviewer who has a potential conflict of interest that may bias (or appear to bias) his or her work is asked to disclose this to theSteering Committee on Practice Guidelines and the work group. Iterative guideline drafts arereviewed by the Steering Committee, other experts, allied organizations, APA members, and
the APA Assembly and Board of Trustees; substantial revisions address or integrate the comments of these multiple reviewers. The development of the APA practice guidelines is notfinancially supported by any commercial organization.
More detail about mechanisms in place to minimize bias is provided in a document available from the APA Department of Quality Improvement and Psychiatric Services, “APA
Guideline Development Process.”
This practice guideline was approved in December 2001 and published in April 2002.

Treatment of Patients With Bipolar Disorder

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GUIDE TO USING THIS PRACTICE GUIDELINEThis practice guideline is based on available evidence and clinical consensus and offers treatment recommendations to help psychiatrists develop plans for the care of adult patients withbipolar disorder. This guideline contains many sections, not all of which will be equally usefulfor all readers. The following guide is designed to help readers find the sections that will bemost useful to them. Part A contains the treatment recommendations for patients with bipolar
disorder. Section I is the summary of the treatment recommendations, which includes the main
treatment recommendations along with codes that indicate the degree of clinical confidence ineach recommendation. Section II is a guide to the formulation and implementation of a treatment plan for the individual patient. This section includes all of the treatment recommendations. Section III, “Special Clinical Features Influencing the Treatment Plan,” discusses a rangeof clinical considerations that could alter the general recommendations discussed in Section II.
Part B, “Background Information and Review of Available Evidence,” will be useful to understand, in detail, the evidence underlying the treatment recommendations of Part A. Section
IV provides an overview of DSM-IV bipolar disorder criteria, features of the disorder, and general information on its natural history, course, and epidemiology. Section V is a structured review and synthesis of published literature regarding available treatments for bipolar disorder.
Because of the paucity of published data on some important clinical questions, unpublishedstudies as well as those in press were also reviewed and included, although they were given considerably less weight than published trials.
Part C, “Future Research Needs,” draws from the previous sections to summarize those areasin which better research data are needed to guide clinical decisions.
To share feedback on this or other published APA practice guidelines, a form is available at
http://www.psych.org/psych_pract/pg/reviewform.cfm.

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INTRODUCTION

This practice guideline summarizes data on the specific somatic and psychosocial interventions
that have been studied in the treatment of bipolar disorder. It begins at the point at which adiagnostic evaluation performed by a psychiatrist has raised the concern that an adult patient
may be suffering from bipolar disorder. According to the criteria defined in DSM-IV-TR (1),patients with bipolar I disorder have experienced at least one episode of mania; they may haveexperienced mixed, hypomanic, and depressive episodes as well. Patients with bipolar II disorder have experienced hypomanic and depressive episodes. Cyclothymic disorder may be diagnosed in those patients who have never experienced a manic, mixed, or major depressive
episode but who have experienced numerous periods of depressive symptoms and numerous
periods of hypomanic symptoms for at least 2 years (or 1 year for children [1]), with no symptom-free period greater than 2 months. Finally, patients with depressive symptoms and periodsof mood elevation who do not meet criteria for any specific bipolar disorder may be diagnosed
with bipolar disorder not otherwise specified. For patients with depressive symptoms and nohistory of mania or hypomania, the psychiatrist should refer to the APA Practice Guideline for
the Treatment of Patients With Major Depressive Disorder (2).
In addition to looking for evidence of the existence of a mood disorder, the initial psychiatric evaluation includes an assessment for the presence of an alcohol or substance use disorderor other somatic factors that may contribute to the disease process or complicate its treatment.
The evaluation also requires a judgment about the safety of the patient and those around him
or her and a decision about the appropriate setting for treatment (e.g., outpatient, day program,inpatient).
The purpose of this guideline is to assist the clinician faced with the task of implementinga specific regimen for the treatment of a patient with bipolar disorder. It should be noted thatmany patients with bipolar disorder also suffer from comorbid psychiatric illnesses. Although
this guideline provides considerations for managing comorbidity in the context of bipolar disorder, it is likely that the psychiatrist will also need to refer to treatment guidelines appropriate
to other diagnoses.
This guideline concerns patients 18 years of age and older. Some comments regarding thetreatment of bipolar disorder in children and adolescents can be found in sections III.B.4 andV.F as well as in more definitive references (3).

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DEVELOPMENT PROCESSThis document is a practical guide to the management of patients—primarily adults 18 yearsof age and older—with bipolar disorder and represents a synthesis of current scientific knowledge and rational clinical practice. This guideline strives to be as free as possible of bias toward
any theoretical approach to treatment.
This practice guideline was developed under the auspices of the Steering Committee on
Practice Guidelines. The process is detailed in a document available from the APA Departmentof Quality Improvement and Psychiatric Services: the “APA Guideline Development Process.”
Key features of this process include the following:• A comprehensive literature review and development of evidence tables.
• Initial drafting by a work group that included psychiatrists with clinical and researchexpertise in bipolar disorder.
• The production of multiple drafts with widespread review; seven organizations and morethan 40 individuals submitted significant comments.
• Approval by the APA Assembly and Board of Trustees.
• Planned revisions at regular intervals.
A computerized search of the relevant literature from MEDLINE and PsycINFO was conducted. Sources of funding were not considered when reviewing the literature.
The first literature search was conducted by searching MEDLINE and PsycINFO for the period from 1992 to 2000. Key words used were “bipolar disorder,” “bipolar depression,” “mania,”“mixed states,” “mixed episodes,” “mixed mania,” “antimanic,” “hypomanic,” “hypomania,”“manic depression,” “prophylactic,” “pharmacotherapy,” “mood stabilizers,” “mood-stabilizing,”“rapid cycling,” “maintenance,” “continuation,” “child and adolescent,” “antidepressants,” “valproate,” “lithium,” “carbamazepine,” “olanzapine,” “risperidone,” “gabapentin,” “topiramate,”“lamotrigine,” “clonazepam,” “divalproex,” “psychotherapy,” “family therapy,” “psychoeducation,” “course,” “epidemiology,” “comorbidity,” “anxiety,” “anxiety disorders,” “attention deficit,” “catatonia,” “elderly,” “family history,” “gender,” “general medical conditions,” “lifeevents,” “personality disorders,” “pregnancy,” “psychosis,” “stress,” “substance-related disorders,”“suicide,” “homicide,” and “violence.” A total of 3,382 citations were found.
An additional MEDLINE search for the period from 1992 to 2001 used the key words “genetic counseling,” “family functioning,” “cross-cultural issues,” and “pharmacokinetics.” A totalof 122 citations were found. A search on PubMed was also conducted through 2001 that used
the search terms “electroconvulsive,” “intravenous drug abuse,” “treatment response,” “pharmacogenetic,” “attention deficit disorder,” “violence,” “aggression,” “aggressive,” “suicidal,” “cognitive impairment,” “sleep,” “postpartum,” “ethnic,” “racial,” “metabolism,” “hyperparathyroidism,” “overdose,” “toxicity,” “intoxication,” “pregnancy,” “breast-feeding,” and “lactation.”
Additional, less formal, literature searches were conducted by APA staff and individual
members of the work group on bipolar disorder.
The recommendations are based on the best available data and clinical consensus with regard
to a particular clinical decision. The summary of treatment recommendations is keyed according
to the level of confidence with which each recommendation is made. In addition, each reference
is followed by a letter code in brackets that indicates the nature of the supporting evidence.

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PART A:
TREATMENT RECOMMENDATIONS FORPATIENTS WITH BIPOLAR DISORDER
I. EXECUTIVE SUMMARY OF RECOMMENDATIONSEach recommendation is identified as falling into one of three categories of endorsement, indicated by a bracketed Roman numeral following the statement. The three categories represent
varying levels of clinical confidence regarding the recommendation:[I] Recommended with substantial clinical confidence.
[II] Recommended with moderate clinical confidence.
[III] May be recommended on the basis of individual circumstances.

왘

A. PSYCHIATRIC MANAGEMENTAt this time, there is no cure for bipolar disorder; however, treatment can decrease the associated morbidity and mortality [I]. Initially, the psychiatrist should perform a diagnostic evaluation and assess the patient’s safety and level of functioning to arrive at a decision about the
optimum treatment setting [I]. Subsequently, specific goals of psychiatric management include
establishing and maintaining a therapeutic alliance, monitoring the patient’s psychiatric status,
providing education regarding bipolar disorder, enhancing treatment compliance, promoting
regular patterns of activity and of sleep, anticipating stressors, identifying new episodes early,
and minimizing functional impairments [I].

왘

B. ACUTE TREATMENT
1. Manic or mixed episodes
The first-line pharmacological treatment for more severe manic or mixed episodes is the initiation of either lithium plus an antipsychotic or valproate plus an antipsychotic [I]. For less illpatients, monotherapy with lithium, valproate, or an antipsychotic such as olanzapine may besufficient [I]. Short-term adjunctive treatment with a benzodiazepine may also be helpful [II].
For mixed episodes, valproate may be preferred over lithium [II]. Atypical antipsychotics are
preferred over typical antipsychotics because of their more benign side effect profile [I], withmost of the evidence supporting the use of olanzapine or risperidone [II]. Alternatives include
carbamazepine or oxcarbazepine in lieu of lithium or valproate [II]. Antidepressants should betapered and discontinued if possible [I]. If psychosocial therapy approaches are used, theyshould be combined with pharmacotherapy [I].
For patients who, despite receiving maintenance medication treatment, experience a manicor mixed episode (i.e., a “breakthrough” episode), the first-line intervention should be to optimize the medication dose [I]. Introduction or resumption of an antipsychotic is sometimes

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necessary [II]. Severely ill or agitated patients may also require short-term adjunctive treatment
with a benzodiazepine [I].
When first-line medication treatment at optimal doses fails to control symptoms, recommended treatment options include addition of another first-line medication [I]. Alternative
treatment options include adding carbamazepine or oxcarbazepine in lieu of an additional firstline medication [II], adding an antipsychotic if not already prescribed [I], or changing fromone antipsychotic to another [III]. Clozapine may be particularly effective in the treatment ofrefractory illness [II]. Electroconvulsive therapy (ECT) may also be considered for patientswith severe or treatment-resistant mania or if preferred by the patient in consultation with thepsychiatrist [I]. In addition, ECT is a potential treatment for patients experiencing mixed episodes or for patients experiencing severe mania during pregnancy [II].
Manic or mixed episodes with psychotic features usually require treatment with an antipsychotic medication [II].

2. Depressive episodes
The first-line pharmacological treatment for bipolar depression is the initiation of either lithium [I] or lamotrigine [II]. Antidepressant monotherapy is not recommended [I]. As an alternative, especially for more severely ill patients, some clinicians will initiate simultaneous
treatment with lithium and an antidepressant [III]. In patients with life-threatening inanition,suicidality, or psychosis, ECT also represents a reasonable alternative [I]. ECT is also a potential
treatment for severe depression during pregnancy [II].
A large body of evidence supports the efficacy of psychotherapy in the treatment of unipolar
depression [I]. In bipolar depression, interpersonal therapy and cognitive behavior therapy may
be useful when added to pharmacotherapy [II]. While psychodynamic psychotherapy has notbeen empirically studied in patients with bipolar depression, it is widely used in addition to
medication [III].
For patients who, despite receiving maintenance medication treatment, suffer a breakthrough depressive episode, the first-line intervention should be to optimize the dose of maintenance medication [II].
When an acute depressive episode of bipolar disorder does not respond to first-line medication treatment at optimal doses, next steps include adding lamotrigine [I], bupropion [II], or
paroxetine [II]. Alternative next steps include adding other newer antidepressants (e.g., a selective serotonin reuptake inhibitor [SSRI] or venlafaxine) [II] or a monoamine oxidase inhibitor(MAOI) [II]. For patients with severe or treatment-resistant depression or depression with psychotic or catatonic features, ECT should be considered [I].
The likelihood of antidepressant treatment precipitating a switch into a hypomanic episodeis probably lower in patients with bipolar II depression than in patients with bipolar I depression. Therefore, clinicians may elect to recommend antidepressant treatment earlier in patientswith bipolar II disorder [II].
Depressive episodes with psychotic features usually require adjunctive treatment with an
antipsychotic medication [I]. ECT represents a reasonable alternative [I].

3. Rapid cycling
As defined in DSM-IV-TR (1) and applied in this guideline, rapid cycling refers to the occurrence of four or more mood disturbances within a single year that meet criteria for a major depressive, mixed, manic, or hypomanic episode. These episodes are demarcated either by partial
or full remission for at least 2 months or a switch to an episode of opposite polarity (e.g., froma major depressive to a manic episode). The initial intervention in patients who experience rapid cycling is to identify and treat medical conditions, such as hypothyroidism or drug or alcoholuse, that may contribute to cycling [I]. Certain medications, particularly antidepressants, mayalso contribute to cycling and should be tapered if possible [II]. The initial treatment for pa-

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tients who experience rapid cycling should include lithium or valproate [I]; an alternative treatment is lamotrigine [I]. For many patients, combinations of medications are required [II].

왘C. MAINTENANCE TREATMENT
Following remission of an acute episode, patients may remain at particularly high risk of relapse
for a period of up to 6 months; this phase of treatment, sometimes referred to as continuation
treatment, is considered in this guideline to be part of the maintenance phase. Maintenanceregimens of medication are recommended following a manic episode [I]. Although few studies
involving patients with bipolar II disorder have been conducted, consideration of maintenancetreatment for this form of the illness is also strongly warranted [II]. The medications with thebest empirical evidence to support their use in maintenance treatment include lithium [I] andvalproate [I]; possible alternatives include lamotrigine [II] or carbamazepine or oxcarbazepine[II]. If one of these medications was used to achieve remission from the most recent depressiveor manic episode, it generally should be continued [I]. Maintenance sessions of ECT may also
be considered for patients whose acute episode responded to ECT [II].
For patients treated with an antipsychotic medication during the preceding acute episode,the need for ongoing antipsychotic treatment should be reassessed upon entering maintenancetreatment [I]; antipsychotics should be discontinued unless they are required for control of persistent psychosis [I] or prophylaxis against recurrence [III]. While maintenance therapy withatypical antipsychotics may be considered [III], there is as yet no definitive evidence that theirefficacy in maintenance treatment is comparable to that of agents such as lithium or valproate.
During maintenance treatment, patients with bipolar disorder are likely to benefit from aconcomitant psychosocial intervention—including psychotherapy—that addresses illness
management (i.e., adherence, lifestyle changes, and early detection of prodromal symptoms)
and interpersonal difficulties [II].
Group psychotherapy may also help patients address such issues as adherence to a treatment
plan, adaptation to a chronic illness, regulation of self-esteem, and management of marital andother psychosocial issues [II]. Support groups provide useful information about bipolar disorder and its treatment [I].
Patients who continue to experience subthreshold symptoms or breakthrough mood episodes may require the addition of another maintenance medication [II], an atypical antipsychotic [III], or an antidepressant [III]. There are currently insufficient data to support one
combination over another. Maintenance sessions of ECT may also be considered for patients
whose acute episode responded to ECT [II].

II. FORMULATION AND IMPLEMENTATION
OF A TREATMENT PLAN
The following discussion regarding the formulation and implementation of a treatment planrefers specifically to patients with bipolar disorder. Every effort has been made to identify andhighlight distinctions between bipolar I and bipolar II disorder in terms of patient response totreatment. However, with few exceptions, data from large trials have been presented in such a
way that making such distinctions is difficult. For the treatment of patients with major depressive disorder, readers should refer to the APA Practice Guideline for the Treatment of Patients
With Major Depressive Disorder (2).
Initial treatment of bipolar disorder requires a thorough assessment of the patient, with particular attention to the safety of the patient and those around him or her as well as attention toTreatment of Patients With Bipolar Disorder11

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possible comorbid psychiatric or medical illnesses. In addition to the current mood state, theclinician needs to consider the longitudinal history of the patient’s illness. Patients frequently
seek treatment during an acute episode, which may be characterized by depression, mania,
hypomania, or a mixture of depressive and manic features. Treatment is aimed at stabilizationof the episode with the goal of achieving remission, defined as a complete return to baseline
level of functioning and a virtual lack of symptoms. (Following remission of a depressive episode, patients may remain at particularly high risk of relapse for a period up to 6 months; thisphase of treatment, sometimes referred to as continuation treatment [4], is considered in thisguideline to be part of maintenance treatment.) After successfully completing the acute phaseof treatment, patients enter the maintenance phase. At this point, the primary goal of treatment
is to optimize protection against recurrence of depressive, mixed, manic, or hypomanic episodes.
Concurrently, attention needs to be devoted to maximizing patient functioning and minimizing
subthreshold symptoms and adverse effects of treatment.
Of note, in the treatment recommendations outlined in this guideline, several references are
made to adding medications or offering combinations of medications. Patients with bipolar
disorder often require such combinations in order to achieve adequate symptom control andprophylaxis against future episodes. However, each additional medication generally increases
the side effect burden and the likelihood of drug-drug interactions or other toxicity and therefore must be assessed in terms of the risk-benefit ratio to the individual patient. This guideline
has attempted to highlight medication interactions used in common clinical practice that areof particular concern (e.g., interactions between lamotrigine and valproate or between carbamazepine and oral contraceptives). In addition, for several of the medications addressed in thisguideline, different preparations or forms are available (e.g., valproic acid and divalproex). Although the guideline refers to these medications in general terms, the form of medication withthe best tolerability and fewest drug interactions should be preferred.
At other times in treatment, it may be necessary to discontinue a medication (e.g., because
of intolerable side effects) or substitute one medication for another. It is preferable to slowly
taper the medication to be discontinued rather than discontinuing it abruptly.
In this revision of the previously published Practice Guideline for the Treatment of Patients
With Bipolar Disorder (5), the term “mood stabilizer” has been omitted. Several definitions ofwhat constitutes a mood stabilizer have been proposed and generally include such criteria as
proven efficacy for the treatment of mania or depression, absence of exacerbation of manic ormixed symptoms, or prophylactic efficacy. Because of the absence of a consensus definition,
this guideline will instead generally refer to specific medications or to the phase of illness inwhich they may be used.

왘

A. PSYCHIATRIC MANAGEMENT
The cross-sectional (i.e., current clinical status) and longitudinal (i.e., frequency, severity, andconsequences of past episodes) context of the treatment decision should guide the psychiatrist
and bipolar disorder patient in choosing from among various possible treatments and treatment settings. Such treatment decisions must be based on knowledge of the potential beneficial
and adverse effects of available options along with information about patient preferences. In
addition, treatment decisions should be continually reassessed as new information becomes
available, the patient’s clinical status changes, or both. Lack of insight or minimization is often
a prominent part of bipolar disorder and may at times interfere with the patient’s ability tomake reasoned treatment decisions, necessitating the involvement of family members or significant others in treatment whenever possible.
At this time, there is no cure for bipolar disorder; however, treatment can significantly decrease the associated morbidity and mortality. The general goals of bipolar disorder treatment
are to assess and treat acute exacerbations, prevent recurrences, improve interepisode function12

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TABLE 1. Characteristics to Evaluate in an Assessment of Suicide Risk in Patients With Bipolar Disorder
Presence of suicidal or homicidal ideation, intent, or plans
Access to means for suicide and the lethality of those means
Presence of command hallucinations, other psychotic symptoms, or severe anxiety
Presence of alcohol or substance use
History and seriousness of previous attempts
Family history of or recent exposure to suicide
Source. Adapted from the APA Practice Guideline for the Treatment of Patients With Major
Depressive Disorder (2).
ing, and provide assistance, insight, and support to the patient and family. Initially, the psychiatrist will perform a diagnostic evaluation and assess the patient’s safety, level of functioning, andclinical needs in order to arrive at a decision about the optimum treatment setting. Subsequently,
specific goals of psychiatric management include establishing and maintaining a therapeutic alliance, monitoring the patient’s psychiatric status, providing education regarding bipolar disorder, enhancing treatment compliance, promoting regular patterns of activity and of sleep,
anticipating stressors, identifying new episodes early, and minimizing functional impairments.

1. Perform a diagnostic evaluation
The evaluation for bipolar disorder requires careful and thorough attention to the clinical history. Patients with bipolar disorder most often exhibit symptoms of depression but may also
exhibit substance use, impulsivity, irritability, agitation, insomnia, problems with relationships,
or other concerns. Patients rarely volunteer information about manic or hypomanic episodes,
so clinicians must probe about time periods with mood dysregulation, lability, or both that areaccompanied by associated manic symptoms (e.g., decreased need for sleep, increased energy).
One way to improve efficiency and increase sensitivity in detecting bipolar disorder is toscreen for it, particularly in patients with depression, irritability, or impulsivity. The Mood Disorder Questionnaire is a 13-item, self-report screening instrument for bipolar disorder that has
been used successfully in psychiatric clinics (6) and in the general population (unpublished2001 study of R.M.A. Hirschfeld). The general principles and components of a complete psychiatric evaluation have been outlined in the APA Practice Guideline for Psychiatric Evaluationof Adults (7).

2. Evaluate the safety of the patient and others and determine a treatment setting
Suicide completion rates in patients with bipolar I disorder may be as high as 10%–15% (8–13);
thus, a careful assessment of the patient’s risk for suicide is critical. The overwhelming majorityof suicide attempts are associated with depressive episodes or depressive features during mixed
episodes. The elements of an evaluation for suicide risk are summarized in Table 1. All patientsshould be asked about suicidal ideation, intention to act on these ideas, and extent of plans or
preparation for suicide. Collateral information from family members or others is critical in assessing suicide risk. Access to means of committing suicide (e.g., medications, firearms) and thelethality of these means should also be determined. Other clinical factors that may increase therisk of a patient acting on suicidal ideation should be assessed; these may include substanceabuse or other psychiatric comorbidity, such as psychosis. The nature of any prior suicide attempts, including their potential for lethality, should be considered.
The ability to predict suicide or violence risk from clinical data is somewhat limited. Consequently, patients who exhibit suicidal or violent ideas or intent require close monitoring.
Whenever suicidal or violent ideas are expressed or suspected, careful documentation of the decision-making process is essential. Hospitalization is usually indicated for patients who are considered to pose a serious threat of harm to themselves or others. If patients refuse, they can be
Treatment of Patients With Bipolar Disorder

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hospitalized involuntarily if their condition meets criteria of the local jurisdiction for involuntary admission. Severely ill patients who lack adequate social support outside of a hospital setting or demonstrate significantly impaired judgment should also be considered for admission
to a hospital. Additionally, those patients who have psychiatric or general medical complications or who have not responded adequately to outpatient treatment may need to be hospitalized. The optimal treatment setting and the patient’s ability to benefit from a different level ofcare should be reevaluated on an ongoing basis throughout the course of treatment.
During the manic phase of bipolar disorder, a calm and highly structured environment is
optimal. Such stimuli as television, videos, music, and even animated conversations can heighten manic thought processes and activities. Patients and their families should be advised thatduring manic episodes, patients may engage in reckless behavior and that, at times, steps should
be taken to limit access to cars, credit cards, bank accounts, and telephones or cellular phones.

3. Establish and maintain a therapeutic alliance
Bipolar disorder is a long-term illness that manifests in different ways in different patients andat different points during its course. Establishing and maintaining a supportive and therapeutic
relationship is critical to the proper understanding and management of an individual patient.
A crucial element of this alliance is the knowledge gained about the course of the patient’s illness that allows new episodes to be identified as early as possible.

4. Monitor treatment response
The psychiatrist should remain vigilant for changes in psychiatric status. While this is true forall psychiatric disorders, it is especially important in bipolar disorder because limited insight on
the part of the patient is so frequent, especially during manic episodes. In addition, small changes in mood or behavior may herald the onset of an episode, with potentially devastating consequences. Such monitoring may be enhanced by knowledge gained over time about particularcharacteristics of a patient’s illness, including typical sequence (e.g., whether episodes of mania
are usually followed by episodes of depression) and typical duration and severity of episodes.

5. Provide education to the patient and to the family
Patients with bipolar disorder benefit from education and feedback regarding their illness,
prognosis, and treatment. Frequently, their ability to understand and retain this information
will vary over time. Patients will also vary in their ability to accept and adapt to the idea thatthey have an illness that requires long-term treatment. Education should therefore be an ongoing process in which the psychiatrist gradually but persistently introduces facts about the illness. Over an extended period of time, such an approach to patient education will assist in
reinforcing the patient’s collaborative role in treating this persistent illness. In this capacity, thepatient will know when to report subsyndromal symptoms. Printed material on cross-sectional
and longitudinal aspects of bipolar illness and its treatment can be helpful, including information available on the Internet (such as that found in the Medical Library at www.medem.com).
Similar educational approaches are also important for family members and significant others.
They too may have difficulty accepting that the patient has an illness and may minimize theconsequences of the illness and the patient’s need for continuing treatment (14–17). A list ofdepressive and bipolar disorder resources, including associations that conduct regular educational meetings and support groups, is provided in Appendix 1.

6. Enhance treatment compliance
Bipolar disorder is a long-term illness in which adherence to carefully designed treatment plans
can improve the patient’s health status. However, patients with this disorder are frequently ambivalent about treatment (18). This ambivalence often takes the form of noncompliance withmedication and other treatments (19, 20), which is a major cause of relapse (21, 22).
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Ambivalence about treatment stems from many factors, one of which is lack of insight. Patients who do not believe that they have a serious illness are not likely to be willing to adhere
to long-term treatment regimens. Patients with bipolar disorder may minimize or deny the reality of a prior episode or their own behavior and its consequences. Lack of insight may be especially pronounced during a manic episode.
Another important factor for some patients is their reluctance to give up the experience ofhypomania or mania (19). The increased energy, euphoria, heightened self-esteem, and ability
to focus may be very desirable and enjoyable. Patients often recall this aspect of the experienceand minimize or deny entirely the subsequent devastating features of full-blown mania or theextended demoralization of a depressive episode. As a result, they are often reluctant to takemedications that prevent elevations in mood.
Medication side effects, cost, and other demands of long-term treatment may be burdensome and need to be discussed realistically with the patient and family members. Many side
effects can be corrected with careful attention to dosing, scheduling, and preparation. Troublesome side effects that remain must be discussed in the context of an informed assessment of therisks and benefits of the current treatment and its potential alternatives.

7. Promote awareness of stressors and regular patterns of activity and sleep
Patients and families can also benefit from an understanding of the role of psychosocial stressors
and other disruptions in precipitating or exacerbating mood episodes. Psychosocial stressors are
consistently found to be increased before both manic and depressive episodes (23). Although
this relationship was previously thought to hold true only for the first few episodes of bipolar
disorder, more recent studies have found that stressors commonly precede episodes in all phasesof the illness (24). Social rhythm disruption with disrupted sleep-wake cycles may specificallytrigger manic (but not depressive) episodes (25). Of course, some episodes may not be associatedwith any discernible life events or stressors. Clinically, the pharmacological management of manicor depressive episodes does not depend on whether stressors preceded the episode. However, patients and families should be informed about the potential consequences of sleep disruption on
the course of bipolar disorder (26). To target vulnerable times and to generate coping strategies
for these stressors, the unique association between specific types of life stressors and precipitating
episodes for each patient should also be addressed (27). It is similarly important to recognize distress or dysfunction in the family of a patient with bipolar disorder, since such ongoing stress
may exacerbate the patient’s illness or interfere with treatment (14, 15, 28, 29).
Patients with bipolar disorder may benefit from regular patterns of daily activities, including
sleeping, eating, physical activity, and social and emotional stimulation. The psychiatrist should
help the patient determine the degree to which these factors affect mood states and develop
methods to monitor and modulate daily activities. Many patients find that if they establish regular patterns of sleeping, other important aspects of life will fall into regular patterns as well.

8. Work with the patient to anticipate and address early signs of relapse
The psychiatrist should help the patient, family members, and significant others recognize earlysigns and symptoms of manic or depressive episodes. Such identification can help the patientenhance mastery over his or her illness and can help ensure that adequate treatment is instituted
as early as possible in the course of an episode. Early markers of episode onset vary from patientto patient but are often usefully predictable across episodes for an individual patient. Many patients experience changes in sleep patterns early in the development of an episode. Other symptoms may be quite subtle and specific to the individual (e.g., participating in religious activities
more or less often than usual). The identification of these early prodromal signs or symptoms
is facilitated by the presence of a consistent relationship between the psychiatrist and the patient as well as a consistent relationship with the patient’s family (27). The use of a graphic display or timeline of life events and mood symptoms can be very helpful in this process (30). First

Treatment of Patients With Bipolar Disorder

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conceived by Kraepelin (31) and Meyer (32) and refined and advanced by Post et al. (30), a life
chart provides a valuable display of illness course and episode sequence, polarity, severity, frequency, response to treatment, and relationship (if any) to environmental stressors. A graphic
display of sleep patterns may be sufficient for some patients to identify early signs of episodes.

9. Evaluate and manage functional impairments
Episodes of mania or depression often leave patients with emotional, social, family, academic,
occupational, and financial problems. During manic episodes, for example, patients may spendmoney unwisely, damage important relationships, lose jobs, or commit sexual indiscretions.
Following mood episodes, they may require assistance in addressing the psychosocial consequences of their actions.
Bipolar disorder is associated with functional impairments even during periods of euthymia,
and the presence, type, and severity of dysfunction should be evaluated (33–35). Impairments
can include deficits in cognition, interpersonal relationships, work, living conditions, and othermedical or health-related needs (36, 37). Identified impairments in functioning should be addressed. For example, some patients may require assistance in scheduling absences from workor other responsibilities, whereas others may require encouragement to avoid major life changes
while in a depressive or manic state. Patients should also be encouraged to set realistic, attainable
goals for themselves in terms of desirable levels of functioning. Occupational therapists may be
helpful with addressing functional impairments caused by bipolar disorder.
Patients who have children may need help assessing and addressing their children’s needs.
In particular, children of individuals with bipolar disorder have genetic as well as psychosocial
risk factors for developing a psychiatric disorder; parents may need help in obtaining a psychiatric evaluation for children who show early signs of mood instability.

왘

B. ACUTE TREATMENT
1. Manic or mixed episodes
For patients experiencing a manic or mixed episode, the primary goal of treatment is the control of symptoms to allow a return to normal levels of psychosocial functioning. The rapid control of agitation, aggression, and impulsivity is particularly important to ensure the safety ofpatients and those around them.
Lithium, valproate, and antipsychotic medications have shown efficacy in the treatment of
acute mania, although the time to onset of action for lithium may be somewhat slower than thatfor valproate or antipsychotics. The combination of an antipsychotic with either lithium or valproate may be more effective than any of these agents alone. Thus, the first-line pharmacologicaltreatment for patients with severe mania is the initiation of either lithium plus an antipsychotic
or valproate plus an antipsychotic. For less ill patients, monotherapy with lithium, valproate, oran antipsychotic such as olanzapine may be sufficient. Alternatives with less supporting evidence
for treatment of manic and mixed states include ziprasidone or quetiapine in lieu of anotherantipsychotic and carbamazepine or oxcarbazepine in lieu of lithium or valproate. (Although efficacy data for oxcarbazepine remain limited, this medication may have equivalent efficacy andbetter tolerability than carbamazepine.) Short-term adjunctive treatment with a benzodiazepine
may also be helpful. In contrast, antidepressants may precipitate or exacerbate manic or mixed
episodes and generally should be tapered and discontinued if possible.
Selection of the initial treatment should be guided by clinical factors such as illness severity,
by associated features (e.g., rapid cycling, psychosis), and by patient preference where possible,
with particular attention to side effect profiles. A number of factors may lead the clinician tochoose one particular agent over another. For example, some evidence suggests a greater efficacy
of valproate compared with lithium in the treatment of mixed states. Also, severely ill and agi-

16

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tated patients who are unable to take medications by mouth may require antipsychotic medications that can be administered intramuscularly. Because of the more benign side effect profile
of atypical antipsychotics, they are preferred over typical antipsychotics such as haloperidol andchlorpromazine. Of the atypical antipsychotics, there is presently more placebo-controlled evidence in support of olanzapine and risperidone.
If psychosocial therapies are used, they should be combined with pharmacotherapy. Perhaps
the only indications for psychotherapy alone for patients experiencing acute manic or mixed
episodes are when all established treatments have been refused, involuntary treatment is not
appropriate, and the primary goals of therapy are focused and crisis-oriented (e.g., resolving ambivalence about taking medication).
For patients who, despite receiving the aforementioned medications, experience a manic ormixed episode (i.e., a “breakthrough” episode), the first-line intervention should be to optimize
the medication dose. Optimization of dosage entails ensuring that the blood level is in the therapeutic range and in some cases achieving a higher serum level (although one still within thetherapeutic range). Introduction or resumption of an antipsychotic is often necessary. Severely
ill or agitated patients may require short-term adjunctive treatment with an antipsychotic agent
or benzodiazepine.
With adequate dosing and serum levels, medications for the treatment of mania generally
exert some appreciable clinical effect by the 10th to the 14th day of treatment. When first-line
medications at optimal doses fail to control symptoms, recommended treatment options include addition of another first-line medication. Alternative treatment options include adding
carbamazepine or oxcarbazepine in lieu of an additional first-line medication, adding an antipsychotic if not already prescribed, or changing from one antipsychotic to another. Of the antipsychotic agents, clozapine may be particularly effective for treatment of refractory illness. As
always, caution should be exercised when combining medications, since side effects may be additive and metabolism of other agents may be affected.
ECT may also be considered for patients with severe or treatment-resistant illness or whenpreferred by the patient in consultation with the psychiatrist. In addition, ECT is a potential
treatment for patients with mixed episodes or for severe mania experienced during pregnancy.
Patients displaying psychotic features during a manic episode usually require treatment withan antipsychotic medication. Atypical antipsychotics are favored because of their more benign
side effect profile.

2. Depressive episodes
The primary goal of treatment in bipolar depression, as with nonbipolar depression, is remissionof the symptoms of major depression with return to normal levels of psychosocial functioning.
An additional focus of treatment is to avoid precipitation of a manic or hypomanic episode.
The first-line pharmacological treatment for bipolar depression is the initiation of either
lithium or lamotrigine. The better supported of these is lithium. While standard antidepressants such as SSRIs have shown good efficacy in the treatment of unipolar depression, for bipolar disorder they generally have been studied as add-ons to medications such as lithium or
valproate; antidepressant monotherapy is not recommended, given the risk of precipitating aswitch into mania. For severely ill patients, some clinicians will initiate treatment with lithium
and an antidepressant simultaneously, although there are limited data to support this approach.
In patients with life-threatening inanition, suicidality, or psychosis, ECT also represents a reasonable alternative. In addition, ECT is a potential treatment for severe depression during pregnancy. Selection of the initial treatment should be guided by clinical factors such as illness
severity, by associated features (e.g., rapid cycling, psychosis), and by patient preference, withparticular attention to side effect profiles.
Small studies have suggested that interpersonal therapy and cognitive behavior therapy may
also be useful when added to pharmacotherapy during depressive episodes in patients with biTreatment of Patients With Bipolar Disorder17

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polar disorder. There have been no definitive studies to date of psychotherapy in lieu of antidepressant treatment for bipolar depression. However, a larger body of evidence supports theefficacy of psychotherapy in the treatment of unipolar depression (2).
For patients who, despite receiving maintenance medication treatment, suffer a breakthroughdepressive episode, the first-line intervention should be to optimize the dose of the maintenancemedication. Optimization of dosage entails ensuring that the serum drug level is in the therapeutic range and in some cases achieving a higher serum level (although one still within the therapeutic range).
For patients who do not respond to optimal maintenance treatment, next steps include adding
lamotrigine, bupropion, or paroxetine. Alternative next steps include adding other newer antidepressants (e.g., another SSRI or venlafaxine) or an MAOI. Although there are few empirical datathat directly compare risk of switch or efficacy among antidepressants in the treatment of bipolar
disorder, tricyclic antidepressants may carry a greater risk of precipitating a switch into hypomania
or mania. Also, while MAOIs have generally demonstrated good efficacy, their side effect profile
may make other agents preferable as initial interventions (2). ECT should be considered for patientswith severe or treatment-resistant depressive episodes or for those episodes with catatonic features.
Patients with psychotic features during a depressive episode usually require adjunctive treatment with an antipsychotic medication. ECT represents a reasonable alternative.
Studies of bipolar depression rarely separate results for patients with bipolar I disorder fromthose of patients with bipolar II disorder. It is not known whether specific pharmacotherapy
regimens differ in efficacy for treatment of bipolar I versus bipolar II depression. However, existing data suggest that for patients with bipolar II disorder, antidepressant treatment—either
alone or in combination with a maintenance medication—is less likely to result in a switch intoa hypomanic episode relative to those with bipolar I disorder (38).

3. Rapid cycling
The initial intervention for patients who experience rapid-cycling episodes of illness is to identify and treat medical conditions that may contribute to cycling, such as hypothyroidism or
drug or alcohol use. Since antidepressants may also contribute to cycling, the need for continued antidepressant treatment should be reassessed; antidepressants should be tapered if possible. The initial treatment for patients who experience rapid-cycling episodes of illness should
include lithium or valproate; an alternative treatment is lamotrigine. In many instances, combinations of medications are required (39, 40); possibilities include combining two of theseagents or combining one of them with an antipsychotic. Because of their more benign side
effect profile, atypical antipsychotics are preferred over typical antipsychotics.

왘C. MAINTENANCE TREATMENT
Maintenance medication treatment is generally recommended following a single manic episode. Although few studies have been conducted involving patients with bipolar II disorder,
consideration of maintenance treatment for this form of the illness is also warranted. Primarygoals of treatment include relapse prevention, reduction of subthreshold symptoms, and reduction of suicide risk. Goals also need to include reduction of cycling frequency and mood instability as well as improvement in overall functioning. Pharmacotherapy must be employed inways that yield good tolerability and do not predispose the patient to nonadherence.
Options with the best empirical evidence to support their use as maintenance treatments
include lithium or valproate; possible alternatives include lamotrigine, carbamazepine, or oxcarbazepine. Despite limited data, oxcarbazepine is included—as it was for acute treatment ofmania—because its efficacy may be similar to that of carbamazepine but with better tolerability. In general, if one of these medications was used to achieve remission from the most recent
18

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depressive or manic episode, it should be continued. Maintenance ECT may also be considered
for patients whose acute episode responded to ECT. Selection of the initial treatment should
be guided by clinical factors such as illness severity, by associated features (e.g., rapid cycling,
psychosis), and by patient preference, with particular attention to side effect profiles.
For patients treated with an antipsychotic medication during the preceding acute episode, theneed for ongoing antipsychotic treatment should be reassessed upon entering the maintenancephase. Since antipsychotic agents, particularly typical antipsychotics, may cause tardive dyskinesia
with long-term use, antipsychotics should be slowly tapered and discontinued unless they are required to control persistent psychosis or provide prophylaxis against recurrence. While maintenance therapy with atypical antipsychotics may be considered, there is as yet no definitive evidence
that their efficacy in maintenance is comparable to that of agents such as lithium or valproate.
Patients with bipolar disorder are likely to gain some additional benefit during the maintenance phase from a concomitant psychosocial intervention that addresses illness management(i.e., adherence, lifestyle changes, and early detection of prodromal symptoms) and interpersonal difficulties. Although not adequately studied to provide evidence-based documentation,
supportive and psychodynamic psychotherapy are widely used in addition to medication.
Group psychotherapy, in conjunction with appropriate medication, may also help patients
address such issues as adherence to a treatment plan, adaptation to a chronic illness, regulationof self-esteem, and management of marital as well as other psychosocial issues.
Support groups provide useful information about bipolar disorder and its treatment. Patients in these groups often benefit from hearing the experiences of others who are struggling
with such issues as denial versus acceptance of the need for medication, problems with side effects, and how to shoulder other burdens associated with the illness and its treatment. Advocacy
groups such as the National Depressive and Manic-Depressive Association and the National
Alliance for the Mentally Ill (Appendix 1) have many local chapters that provide both supportand educational material to patients and their families.
Although maintenance medication combinations are often associated with increases in side
effects, use of such regimens should be considered for patients who have not responded adequately to simpler regimens. The addition of another maintenance medication, an atypicalantipsychotic, or an antidepressant may be necessary for patients who experience either continuing high levels of subthreshold symptoms or a breakthrough episode of illness. There are
currently insufficient data to support one combination over another. Maintenance ECT may
also be considered for patients whose acute episode responded to ECT.

III. SPECIAL CLINICAL FEATURES
INFLUENCING THE TREATMENT PLAN왘

A. PSYCHIATRIC FEATURES
1. Psychosis
Psychotic symptoms (e.g., delusions, hallucinations) are commonly seen during episodes of either mania or depression but are more common in the former, appearing in over one-half ofmanic episodes (41). Mood-congruent features during a manic episode probably are not predictive of a poorer outcome, although early onset (before age 21) of psychotic mania may predict a more severe disorder (42). Mood-incongruent features have been identified in some (43)Treatment of Patients With Bipolar Disorder

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but not all (44) studies to be a predictor of a shorter time in remission. The presence of psychotic features during a manic episode may not require an antipsychotic medication, althoughmost clinicians prescribe them in addition to a maintenance agent (45).

2. Catatonia
Catatonic features may develop in up to one-third of patients during a manic episode (46). The
most commonly observed symptoms of catatonia in mania are motor excitement, mutism, andstereotypic movements. Because catatonic symptoms are seen in other psychiatric and neurological disorders, a careful assessment is indicated for an accurate diagnosis. In addition, patients
who exhibit catatonic stupor may go on to show more typical signs and symptoms of mania during the same episode of illness (47). The presence of catatonic features during the course of amanic episode is associated with greater episode severity, mixed states, and somewhat poorer
short-term outcomes (46). In treating catatonia, neuroleptics have generally exhibited poor efficacy (48). In contrast, prospective studies have demonstrated the efficacy of lorazepam in thetreatment of catatonic syndromes, including those associated with mania (49–52). Since ECT
is probably the most effective treatment for catatonic syndromes regardless of etiology, ECTshould be considered if benzodiazepines do not result in symptom resolution (48).

3. Risk of suicide, homicide, and violence
Like those suffering from major depression, patients with bipolar disorder are at high risk forsuicide (53, 54). The frequency of suicide attempts appears similar for the bipolar I and bipolar
II subtypes (55, 56). Individuals with bipolar disorder repeatedly have been shown to havegreater overall mortality than the general population (41). Although much of this risk reflects
the higher rate of suicide, cardiovascular and pulmonary mortality among patients with untreatedbipolar disorder is also high (41, 57).
Known general risk factors for suicide also apply to patients with bipolar disorder. These
include a history of suicide attempts, suicidal ideation, comorbid substance abuse, comorbid
personality disorders (58), agitation, pervasive insomnia, impulsiveness (59), and family history of suicide. Among the phases of bipolar disorder, depression is associated with the highest
suicide risk, followed by mixed states and presence of psychotic symptoms, with episodes ofmania being least associated with suicide (8, 56). Suicidal ideation during mixed states has beencorrelated with the severity of depressive symptoms (10). In general, a detailed evaluation of
the individual patient is necessary to assess suicide risk (Table 1). Judgment of suicide risk isinherently imperfect; therefore, risks and benefits of intervention should be carefully weighed
and documented.
Long-term treatment with lithium has been associated with reduction of suicide risk (56,60). Whether this reflects an anti-impulsivity factor beyond lithium’s mood-stabilizing effect is
not yet clear. Lithium may also diminish the greater mortality risk observed among bipolar disorder patients from causes other than suicide (61). It is unknown whether prolonged survival
is also seen with the anticonvulsant maintenance agents.
Clinical experience attests to the presence of violent behavior in some patients with bipolar
disorder, and violence may be an indication for hospitalization (41). Comorbid substanceabuse and psychosis may contribute to the threat of criminal violence or aggression (62–64).

4. Substance use disorders
Bipolar disorder with a comorbid substance use disorder is a very common presentation, withbipolar disorder patients of both sexes showing much higher rates of substance use than the general population (65). For example, the Epidemiologic Catchment Area study found rates of alcohol abuse or dependence in 46% of patients with bipolar disorder compared with 13% for thegeneral population. Comparable drug abuse and dependence figures are 41% and 6%, respec20

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tively (66, 67). Substance abuse may obscure or exacerbate endogenous mood swings. Conversely, comorbid substance use disorder may be overlooked in patients with bipolar disorder (68,69). Substance abuse may also precipitate mood episodes or be used by patients to ameliorate
the symptoms of such episodes. Comorbid substance use is typically associated with fewer andslower remissions, greater rates of suicide and suicide attempts, and poorer outcome (70–73).
Treatment for substance abuse and bipolar disorder should proceed concurrently when possible. It is also helpful to obtain consultation from an addiction expert, such as an addiction
psychiatrist, or to arrange for concomitant treatment of the bipolar disorder and the substanceuse disorder in a dual-diagnosis program.
Alcohol abuse and its effects may affect bipolar disorder pharmacotherapy. For instance,
alcohol-related dehydration may raise lithium levels to toxicity. Hepatic dysfunction fromchronic alcohol abuse or from hepatitis associated with intravenous substance use may alter
plasma levels of valproate and carbamazepine (74). If the hepatic dysfunction is severe, the useof these hepatically metabolized medications may be problematic. In these cases, coordination
with the patient’s primary care physician or gastroenterologist is recommended (75).

5. Comorbid psychiatric conditions
Patients with comorbid personality disorders pose complicated diagnostic pictures. They areclearly at greater risk for experiencing intrapsychic and psychosocial stress that can precipitate
or exacerbate mood episodes. Patients with comorbid personality disorders generally havegreater symptom burden, lower recovery rates from episodes, and greater functional impairment (76). In addition, these patients may have particular difficulty adhering to long-term
treatment regimens (77).
Relative to the general population, individuals with bipolar disorder are at greater risk forcomorbid anxiety disorders, especially panic disorder and obsessive-compulsive disorder. Comorbid anxiety disorders may predict a longer time to recovery of mood episodes (78). Treatment for the bipolar disorder and the comorbid anxiety disorder should proceed concurrently.
The presence of comorbid attention-deficit/hyperactivity disorder (ADHD) in adults andchildren with bipolar disorder may make it difficult to monitor changes in mood states. Of
note, adults with bipolar disorder and comorbid ADHD are likely to have experienced a muchearlier age at onset of their mood disorder relative to those without comorbid ADHD (79).

왘B. DEMOGRAPHIC AND PSYCHOSOCIAL FACTORS
1. Gender
A number of issues related to gender must be considered when treating patients with bipolar
disorder. Hypothyroidism is more common in women, and women may be more susceptible
to the antithyroid effects of lithium (80). Additionally, rapid cycling is more common in women(81, 82). Treatment with antipsychotics and, to a lesser extent, SSRIs may elevate serum levelsof prolactin and result in galactorrhea, sexual dysfunction, menstrual disorders, and impaired
fertility (83, 84).

2. Pregnancy
Because many medications used to treat bipolar disorder are associated with a higher risk ofbirth defects, the psychiatrist should encourage effective contraceptive practices for all female
patients of childbearing age who are receiving pharmacological treatment (85, 86). Since carbamazepine, oxcarbazepine, and topiramate increase the metabolism of oral contraceptives, women taking these medications should not rely on oral contraceptives for birth control (87–89).
This effect does not occur with other medications used to treat bipolar disorder.

Treatment of Patients With Bipolar Disorder21

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Multiple clinical issues arise in relationship to pregnancy in bipolar disorder patients. In order to permit discussion of the risks and benefits of therapeutic options, a pregnancy should beplanned in consultation with the psychiatrist whenever possible. Because of the higher genetic
risk for bipolar disorder (90–92), patients with bipolar disorder who are considering having
children may also benefit from genetic counseling (22).
a) Continuing/discontinuing medications
Around the time of pregnancy, the risks and benefits of continuing versus discontinuing treatment require the most thoughtful judgment and discussion among the patient, the psychiatrist,
the obstetrician, and the father. Specific options include continuing medication throughout
pregnancy, discontinuing medications at the beginning of pregnancy or before conception, anddiscontinuing the medication only for the first trimester.
In clinical decision making, the potential teratogenic risks of psychotropic medications
must be balanced against the risk of no prophylactic treatment, with the attendant risks of illness (93). Although the course of bipolar disorder during pregnancy is still unclear, some evidence suggests that pregnancy does not alter the rate of mood episodes compared with othertimes (94). However, in patients who have been stable on a regimen of lithium, the rate of recurrent mood episodes is clearly increased by lithium discontinuation, particularly when discontinuation is abrupt (94). Should the decision be made to discontinue medication, the woman
should be advised about the potentially greater risk of mood episode recurrence with rapid discontinuation of lithium (and possibly other maintenance agents) compared with a slower taperover many weeks (95).
Although direct evidence of a negative effect of untreated psychiatric disorders on fetal development is lacking, antenatal stress, depression, and anxiety are linked with a variety of abnormalities in newborns (96–101). Additionally, during a manic episode, women are at risk of increasing
their consumption of alcohol and other drugs, thus conferring additional dangers to the fetus.
b) Prenatal exposure to medicationsFirst-trimester exposure to lithium, valproate, or carbamazepine is associated with a greater riskof birth defects. With lithium exposure the absolute risk for Ebstein’s anomaly, a cardiovascular
defect, is 1–2 per 1,000. This is approximately 10–20 times greater than the risk in the general
population (102). Exposure to carbamazepine and valproate during the first trimester is associated with neural tube defects at rates of up to 1% and 3%–5%, respectively (85). Bothcarbamazepine and valproate exposure have also been associated with craniofacial abnormalities (103, 104). Other congenital defects that have been observed with valproate include limb
malformations and cardiac defects (104). Little is known about the potential teratogenicity oflamotrigine, gabapentin, or other newer anticonvulsants.
No teratogenic effects have been demonstrated with tricyclic antidepressants. Near term,
however, their use has been associated with side effects in the neonate (105). The SSRIs seemto be relatively benign in their risks to exposed fetuses (106), with safety data being strongest
for fluoxetine and citalopram. Although data with bupropion, mirtazapine, nefazodone, trazodone, and venlafaxine are limited (105), none of the newer antidepressants has been shown to
be teratogenic (106, 107). Nonetheless, caution must be exercised if they are prescribed to treat
bipolar depression in pregnant women (93).
Antipsychotic agents may be needed to treat psychotic features of bipolar disorder during
pregnancy, but they may also represent an alternative to lithium for treating symptoms of mania (105). High-potency antipsychotic medications are preferred during pregnancy, since they
are less likely to have associated anticholinergic, antihistaminergic, or hypotensive effects. In
addition, there is no evidence of teratogenicity with exposure to haloperidol, perphenazine,
thiothixene, or trifluoperazine (105). When high-potency antipsychotic medications are usednear term, neonates may show extrapyramidal side effects, but these are generally short-lived
22

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(108). To limit the duration of such effects, however, long-acting depot preparations of antipsychotic medications are not recommended during pregnancy (105). For newer antipsychotic
agents such as risperidone, olanzapine, clozapine, quetiapine, and ziprasidone, little is known
about the potential risks of teratogenicity or the potential effects in the neonate.
The risk of teratogenicity with benzodiazepines is not clear (108). Early studies, primarily
with diazepam and chlordiazepoxide, suggested that first-trimester exposure may have led tomalformations, including facial clefts, in some infants. Later studies showed no significant increases in specific defects or in the overall incidence of malformations (108). A recent metaanalysis of the risk of oral cleft or major malformations showed no association with fetal exposure to benzodiazepines in pooled data from cohort studies, but a greater risk was reported on
the basis of pooled data from case-control studies (109). In general, however, teratogenic risks
are thought likely to be small with benzodiazepines (105). Near term, use of benzodiazepines
may be associated with sedation in the neonate. Withdrawal symptoms resulting from dependence may also be seen in the neonate (108). As a result, if benzodiazepines are used during
pregnancy, lorazepam is generally preferred (105).
ECT is also a potential treatment for severe mania or depression during pregnancy (110).
In terms of teratogenicity, the short-term administration of anesthetic agents with ECT may
present less risk to the fetus than pharmacological treatment options (111). The APA Task
Force Report on ECT contains additional details on the use of ECT during pregnancy (110).
c) Prenatal monitoring
Women who choose to remain on regimens of lithium, valproate, or carbamazepine during
pregnancy should have maternal serum α-fetoprotein screening for neural tube defects before
the 20th week of gestation, with amniocentesis as well as targeted sonography performed forany elevated α-fetoprotein values (105). Women should also be encouraged to undergo highresolution ultrasound examination at 16–18 weeks gestation to detect cardiac abnormalities in
the fetus. Since hepatic metabolism, renal excretion, and fluid volume are altered during pregnancy and the perinatal period, serum levels of medications should be monitored and doses
adjusted if indicated. At delivery, the rapid fluid shifts in the mother will markedly increaselithium levels unless care is taken to either lower the lithium dose, ensure hydration, or both(112). Discontinuing lithium on the day of delivery is probably not necessary and may be unwise given the high risk for postpartum mood episodes and the greater risk of recurrence if lithium is discontinued in women with bipolar disorder (94, 112).
d) Postpartum issues
The postpartum period is consistently associated with a markedly greater risk for relapse into
mania, depression, or psychosis. For women with bipolar disorder, the rate of postpartum relapse
is as high as 50% (86, 94). Women who have had severe postpartum affective episodes in thepast are at highest risk to have another episode of illness after subsequent pregnancies. Despite
a paucity of studies, it is generally considered that prophylactic medications such as lithium or
valproate may prevent postpartum mood episodes in women with bipolar disorder (113). Also,
since changes in sleep are common in the postpartum period, women should be educated about
the need to maintain normal sleep patterns to avoid precipitating episodes of mania.
e) Infant medication exposure through breast-feeding
All medications used in the treatment of bipolar disorder are secreted in breast milk in varying
degrees, thereby exposing the neonate to maternally ingested medication (114). However, aswith the risks of medications during pregnancy, risks of breast-feeding with psychotropic medications must be weighed against the benefits of breast-feeding (115, 116). Because lithium issecreted in breast milk at 40% of maternal serum concentration, most experts have recommended against its use in mothers who choose to breast-feed (105). Fewer data on breast-feeding are
Treatment of Patients With Bipolar Disorder

23

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available for carbamazepine and valproate. Although it is generally considered safe, potential
risks should always be considered. Little is known about lamotrigine exposure in breast-fed
neonates; however, levels in the infant may reach 25% of maternal serum levels (117). Consequently, the potential for pharmacological effects, including a risk for life-threatening rash,should be taken into consideration (118). With other psychotropic medications (including antipsychotics, antidepressants, and benzodiazepines), there are few reports of specific adverse effects
in breast-feeding infants. Nonetheless, these drugs are found in measurable quantities in breast
milk and could conceivably affect central nervous system functioning in the infant (118).

3. Cross-cultural issues
Culture can influence the experience and communication of symptoms of depression and mania. Underdiagnosis or misdiagnosis, as well as delayed detection of early signs of recurrence,
can be reduced by being alert to specific ethnic and cultural differences in reporting complaintsof a major mood episode. Specifically, minority patients (particularly African and Hispanic
Americans) with bipolar disorder are at greater risk for being misdiagnosed with schizophrenia(119, 120). This greater risk appears to result from clinicians failing to elicit affective symptoms
in minority patients with affective psychoses (121).
Ethnicity and race must also be taken into consideration when prescribing medications,since ethnic and racial groups may differ in their metabolism of some medications (122, 123).
For example, relative to Caucasian patients, Chinese patients have a lower average activity of
the cytochrome P-450 isoenzyme 2D6 (123). As a result, they typically require lower doses ofantidepressants and antipsychotics that are metabolized by this enzyme (122). Similar deficits
in average activity of the cytochrome P-450 isoenzyme 2C19 have been found in Chinese, Japanese, and Korean patients compared with Caucasians (123).

4. Children and adolescents
The prevalence of bipolar disorder in a community sample of children and adolescents was 1%;
an additional 5.7% had mood symptoms that met criteria for bipolar disorder not otherwise
specified (124). Although DSM-IV-TR criteria are used to diagnose bipolar disorder in childhood and adolescence, the clinical features of childhood bipolar disorder differ from bipolar disorder in adults. Children with bipolar disorder often have mixed mania, rapid cycling, andpsychosis (125). Child and adolescent bipolar disorder is often comorbid with attention deficit
and conduct disorders (126–128). For children and adolescents in a current manic episode, 1year recovery rates of 37.1% and relapse rates of 38.3% have been reported (1, 129). In a 5-year
prospective follow-up of adolescents experiencing bipolar disorder, relapse rates of 44% were
found (130). Despite the severity and chronicity of this disorder in children and adolescents andits devastating impact on social, emotional, and academic development, treatment research has
lagged far behind that of adult bipolar disorder.
Although there is more information available about the use of lithium and divalproex inchildren and adolescents with bipolar disorder, other medication treatment options include
atypical antipsychotics, carbamazepine, and combinations of these medications.
Treatment with a maintenance agent should continue for a minimum of 18 months after stabilization of a manic episode. There is evidence that ultimate stabilization takes a number of years(131). In addition, lithium discontinuation has been shown to increase relapse rates in adolescentswith bipolar disorder: relapse occurred within 18 months in 92% of those who discontinued lithium versus 37% of those who continued lithium (132). Consequently, medication discontinuation should be done gradually at a time when there are no major anticipated stressors.
Psychiatric comorbidity may complicate the diagnosis and treatment of bipolar disorder inchildren and adolescents. The presence of ADHD, especially in children and adolescents, confounds the assessment of mood changes in patients with bipolar disorder. Early manifestationsof mania and hypomania can be particularly difficult to distinguish from the ongoing symp24

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toms of ADHD. Careful tracking of symptoms and behaviors is helpful. In addition, the presenceof ADHD is associated with higher rates of learning disabilities, which should be addressed intreatment planning.
Youths with bipolar disorder are at greater risk for substance use disorders (133, 134). Comorbid substance use has been shown to complicate the course of bipolar disorder and its treatment (135). Short-term treatment with lithium (136) and divalproex (137) may be useful inthese conditions. However, in a 2-year follow-up of hospitalized manic adolescents, the bipolar
disorder patients who continued to abuse substances had more manic episodes and poorer
functioning than early-onset bipolar disorder patients who did not exhibit comorbid substanceabuse. In contrast, cessation of substance use was associated with fewer episodes and greater
functional improvement at the 4-year follow-up point (135).

5. Geriatric patients
In patients over 65 years of age, prevalence rates of bipolar disorder range from 0.1% to 0.4%
(138). In addition, 5%–12% of geriatric psychiatry admissions are for bipolar disorder (138).
Relative to patients with onset of mania at a younger age, those with onset at an older age tend
to have less of a family history of bipolar disorder. They may also have longer episode durations
or more frequent episodes of illness (139). Of individuals with onset of mania at older ages, onehalf have had previous depressive episodes, often with a long latency period before the first manic
episode (140).
Manic syndromes in geriatric patients may also be associated with general medical conditions, medications used to treat those conditions, or substance use (138–140). The new onsetof mania in later life is particularly associated with high rates of medical and neurological diseases (139–141). Right hemispheric cortical or subcortical lesions are especially common. Relative
to elderly patients with multiple episodes of mania, geriatric patients with a first episode of mania have a higher risk of mortality (141). Therefore, any patient with a late onset of manic symptoms should be evaluated carefully for general medical and neurological causes (138–140).
General principles for treating geriatric mania are similar to those for younger adults. Olderpatients will usually require lower doses of medications, since aging is associated with reductions
in renal clearance and volume of distribution (142). Concomitant medications and medical conditions may also alter the metabolism or excretion of psychotropic medications (139). Older patients may also be more sensitive to side effects because of greater end-organ sensitivity. Manyelderly patients tolerate only low serum levels of lithium (e.g., 0.4–0.6 meq/liter) (138) and can
respond to these levels. Those who tolerate low serum lithium levels but who are not showing
benefit should have slow dose increases to yield serum levels in the usual therapeutic range.
Older patients may be more likely to develop cognitive impairment with medications suchas lithium or benzodiazepines (138). They may also have difficulty tolerating antipsychotic
medications and are more likely to develop extrapyramidal side effects and tardive dyskinesia
than younger individuals (143). With some antipsychotics and antidepressants, orthostatic
hypotension may be particularly problematic and increases the risk of falls. Use of benzodiazepines and of neuroleptics also has been associated with greater risks of falls and hip fracturesin geriatric patients (144).

왘

C. CONCURRENT GENERAL MEDICAL CONDITIONSIn the presence of a severe medical disorder, the disorder itself or the medications used to treat itshould always be considered as possible causes of a manic episode. Neurological conditions commonly associated with secondary mania are multiple sclerosis, lesions involving right-side subcortical structures, and lesions of cortical areas with close links to the limbic system (145). L-Dopa
and corticosteroids are the most common medications associated with secondary mania (146).
Treatment of Patients With Bipolar Disorder

25

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The presence of a general medical condition may also exacerbate the course or severity of
bipolar disorder or complicate its treatment (147). For example, the course of bipolar disorder
may be exacerbated by any condition that requires intermittent or regular use of steroids (e.g.,asthma, inflammatory bowel disease) or that leads to abnormal thyroid functioning. In addition, treatment of patients with bipolar disorder may be complicated by conditions requiring
the use of diuretics, angiotensin-converting enzyme inhibitors, nonsteroidal anti-inflammatory
drugs, cyclooxygenase-2 inhibitors, or salt-restricted diets, all of which affect lithium excretion.
Conditions or their treatments that are associated with abnormal cardiac conduction or rhythmor that affect renal or hepatic function may further restrict the choice or dosage of medications.
In HIV-infected patients, lower doses of medications are often indicated because of patients’greater sensitivity to side effects and because of the potential for drug-drug interactions. Special
considerations in the treatment of HIV-infected patients are presented in the APA Practice
Guideline for the Treatment of Patients With HIV/AIDS (148).
Whenever patients are taking more than one medication, the possibility of adverse drug-druginteractions should always be considered. Patients should be educated about the importance of
informing their psychiatrist and other physicians about their current medications whenever
new medications are prescribed. Clinicians should also inquire about patient use of herbal preparations and over-the-counter medications.

PART B:BACKGROUND INFORMATION AND
REVIEW OF AVAILABLE EVIDENCE
IV. DISEASE DEFINITION, NATURAL HISTORYAND COURSE, AND EPIDEMIOLOGY왘A. DEFINITION OF BIPOLAR DISORDER
According to DSM-IV-TR (1), patients with bipolar I disorder have had at least one episodeof mania (criteria for a manic episode are presented in Table 2). Some patients have had previous depressive episodes (Table 3), and most patients will have subsequent episodes that can beeither manic or depressive. Hypomanic and mixed episodes (Table 4 and Table 5, respectively)
can occur, as well as significant subthreshold mood lability between episodes. Patients meeting
criteria for bipolar II disorder have a history of major depressive episodes and hypomanic episodes only. Patients may also exhibit significant evidence of mood lability, hypomania, and depressive symptoms but fail to meet duration criteria for bipolar II disorder, thereby leading toa diagnosis of bipolar disorder not otherwise specified. Finally, cyclothymic disorder may bediagnosed in those patients who have never experienced a manic, mixed, or major depressive
episode but who experience numerous periods of depressive symptoms and numerous periodsof hypomanic symptoms for at least 2 years (1 year in children), with no symptom-free period
greater than 2 months. The subtypes of bipolar disorder, as well as selected other affective illnesses, are summarized and compared in Table 6.
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TABLE 2. Diagnostic Criteria for a Manic EpisodeA. A distinct period of abnormally and persistently elevated, expansive, or irritable mood,lasting at least 1 week (or any duration if hospitalization is necessary).
B. During the period of mood disturbance, three (or more) of the following symptoms havepersisted (four if the mood is only irritable) and have been present to a significant degree:
1) Inflated self-esteem or grandiosity2) Decreased need for sleep (e.g., feels rested after only 3 hours of sleep)3) More talkative than usual or pressure to keep talking4) Flight of ideas or subjective experience that thoughts are racing5) Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external
stimuli)6) Increase in goal-directed activity (either socially, at work or school, or sexually) or
psychomotor agitation
7) Excessive involvement in pleasurable activities that have a high potential for painfulconsequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or
foolish business investments)
C. The symptoms do not meet criteria for a mixed episode.
D. The mood disturbance 1) is sufficiently severe to cause marked impairment in
occupational functioning, usual social activities, or relationships with others, 2)
necessitates hospitalization to prevent harm to self or others, or 3) has psychotic features.
E. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug ofabuse, a medication, or other treatment) or a general medical condition (e.g.,
hyperthyroidism).
Source. Adapted from DSM-IV-TR; manic-like episodes that are clearly caused by somatic
antidepressant treatment (e.g., medication, ECT, light therapy) should not count toward a diagnosis of bipolar I disorder.
In addition to providing definitions of bipolar disorder, DSM-IV-TR also includes specifiers describing the course of recurrent episodes, such as seasonal pattern, longitudinal course(with or without full interepisode recovery), and rapid cycling.
Some investigators have advocated moving from a categorical to a more dimensional perspective in characterizing bipolar disorder. In particular, this perspective includes the conceptof a bipolar spectrum that would encompass a range of presentations not currently consideredbipolar (149). For example, a patient with antidepressant-induced hypomanic symptoms
would be considered to have a form of bipolar disorder under the spectrum conceptualization.

왘

B. NATURAL HISTORY AND COURSE
Bipolar disorder is generally an episodic, lifelong illness with a variable course. The first episodeof bipolar disorder may be manic, hypomanic, mixed, or depressive. Men are more likely than
women to be initially manic, but both are more likely to have a first episode of depression. Patients with untreated bipolar disorder may have more than 10 total episodes of mania and depression during their lifetime, with the duration of episodes and interepisode periods stabilizing
after the fourth or fifth episode (150). Often, 4 years or more may elapse between the first andsecond episodes, but the intervals between subsequent episodes usually narrow. However, it
must be emphasized that variability is the hallmark of this illness. Thus, when taking a history,
a number of longitudinal issues must be considered, including the number of prior episodes,
the average length and severity of episodes, average interepisode duration, and the interval since
the last episode of mania or depression.
Treatment of Patients With Bipolar Disorder27

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TABLE 3. Diagnostic Criteria for a Major Depressive EpisodeA. Five (or more) of the following symptoms have been present nearly every day during thesame 2-week period and represent a change from previous functioning; at least one of thesymptoms is either depressed mood or loss of interest or pleasure:1) Depressed mooda most of the day as indicated by either subjective report (e.g., feels
sad or empty) or observation made by others (e.g., appears tearful)2) Markedly diminished interest or pleasure in all, or almost all, activities most of theday (as indicated by either subjective account or observation made by others)3) Significant weight loss when not dieting,b weight gain (e.g., a change of more than
5% of body weight in a month), or a decrease or increase in appetite
4) Insomnia or hypersomnia
5) Psychomotor agitation or retardation (observable by others, not merely subjective
feelings of restlessness or being slowed down)
6) Fatigue or loss of energy7) Feelings of worthlessness or excessive or inappropriate guilt (which may bedelusional)c8) Diminished ability to think or concentrate or indecisiveness (either by subjective
account or as observed by others)
9) Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without
a specific plan, or previous suicide attempt or a specific plan for committing suicide
B. The symptoms do not meet criteria for a mixed episode.
C. The symptoms cause clinically significant distress or impairment in social, occupational,
or other important areas of functioning.
D. The symptoms are not due to the direct physiological effects of a substance (e.g., a drugof abuse, a medication) or a general medical condition (e.g., hypothyroidism).
E. The symptoms are not better accounted for by bereavement (i.e., after the loss of a lovedone) and have persisted for longer than 2 months or are characterized by marked
functional impairment, morbid preoccupation with worthlessness, suicidal ideation,
psychotic symptoms, or psychomotor retardation.
Source. Adapted from DSM-IV-TR; mood-incongruent delusions, hallucinations, and symptoms that are clearly due to a general medical condition should not count toward a diagnosis
of major depressive disorder.
aIn children and adolescents, mood can also be irritable.
bIn children, can also include failure to make expected weight gains.
cSymptoms extend beyond mere self-reproach or guilt about being sick.
Frequently, a patient will experience several episodes of depression before a manic episodeoccurs (34, 151). Consequently, bipolar disorder should always be considered in the differential diagnosis of depression. Patients very often do not report prior episodes of mania andhypomania and instead seek treatment for complaints of depression, delaying correct diagnosis(5, 152–157). For a patient who is not educated about bipolar disorder, symptoms of dysphoric
hypomania may not be recognized or reported. Therefore, the psychiatrist needs to ask explicitly about prior manic or hypomanic episodes, since knowledge of their presence can influence
treatment decisions. The psychiatrist should also ask about a family history of mood disorders,
including mania and hypomania. Consultation with family members and significant others
may be extremely useful in establishing family history and identifying prior affective episodes.
In addition to substance abuse and risk-taking behavior, other cross-sectional features that canhave an impact on diagnosis and treatment planning include the presence of psychotic symptoms
or cognitive impairment and the risk of suicide or violence to persons or property (41).
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TABLE 4. Diagnostic Criteria for a Hypomanic EpisodeA. A distinct period of persistently elevated, expansive, or irritable mood, lasting at least
4 days, that is clearly different from the usual nondepressed mood.
B. During the period of mood disturbance, three (or more) of the following symptoms havepersisted (four if the mood is only irritable) and have been present to a significant degree:
1) Inflated self-esteem or grandiosity2) Decreased need for sleep (e.g., feels rested after only 3 hours of sleep)3) More talkative than usual or pressure to keep talking4) Flight of ideas or subjective experience that thoughts are racing5) Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external
stimuli)6) Increase in goal-directed activity (either socially, at work or school, or sexually) or
psychomotor agitation
7) Excessive involvement in pleasurable activities that have a high potential for painfulconsequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or
foolish business investments)
C. The episode is associated with an unequivocal change in functioning that is
uncharacteristic of the person when not symptomatic.
D. The disturbance in mood and the change in functioning are observable by others.
E. The episode 1) is not severe enough to cause marked impairment in social or
occupational functioning, 2) does not necessitate hospitalization, and 3) does not havepsychotic features.
F. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug ofabuse, a medication, or other treatment) or a general medical condition (e.g.,
hyperthyroidism).
Source. Adapted from DSM-IV-TR; hypomanic-like episodes that are clearly caused by somatic
antidepressant treatment (e.g., medication, ECT, light therapy) should not count toward a diagnosis of bipolar II disorder.
Suicide rates are high among bipolar disorder patients. Completed suicide occurs in an estimated 10%–15% of individuals with bipolar I disorder. Suicide is more likely to occur during
a depressive or a mixed episode (8–13). Pharmacotherapy may substantially reduce the risk ofsuicide (56, 60, 153). For example, in an 11-year follow-up study of 103 patients with bipolar
disorder who were receiving lithium, death rates were well below those expected for this groupon the basis of age and sex (154).
Bipolar disorder causes substantial psychosocial morbidity, frequently affecting patients’ relationships with spouses or partners, children, and other family members as well as their occupation and other aspects of their lives. Even during periods of euthymia, patients may
experience impairments in psychosocial functioning or residual symptoms of depression ormania/hypomania. It is estimated that as many as 60% of people diagnosed with bipolar I disorder experience chronic interpersonal or occupational difficulties and subclinical symptoms
between acute episodes (13, 33, 34, 158–164). Divorce rates are substantially higher in patientswith bipolar disorder, approaching two to three times the rate of comparison subjects (152).
The occupational status of patients with bipolar disorder is twice as likely to deteriorate as thatof comparison subjects (152). Patients’ ability to care for themselves, degree of disability or distress, childbearing status or plans, availability of supports such as family or friends, and resources
such as housing and finances also bear on treatment plans.

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TABLE 5. Diagnostic Criteria for a Mixed EpisodeA. The criteria are met both for a manic episode and for a major depressive episode (except
for duration) nearly every day during at least a 1-week period.
B. The mood disturbance 1) is sufficiently severe to cause marked impairment in occupational functioning, usual social activities, or relationships with others, 2) necessitates
hospitalization to prevent harm to self or others, or 3) has psychotic features.
C. The symptoms are not due to the direct physiological effects of a substance (e.g., a drugof abuse, a medication, or other treatment) or a general medical condition (e.g.,
hyperthyroidism).
Source. Adapted from DSM-IV-TR; mixed-like episodes that are clearly caused by somatic
antidepressant treatment (e.g., medication, ECT, light therapy) should not count toward adiagnosis of bipolar I disorder.

왘

C. EPIDEMIOLOGY
Bipolar I disorder affects approximately 0.8% of the adult population, with estimates from
community samples ranging between 0.4% and 1.6%. These rates are consistent across diverse
cultures and ethnic groups (165). Bipolar II disorder affects approximately 0.5% of the population (156). While bipolar II disorder is apparently more common in women (81), bipolar I
disorder affects men and women fairly equally. These estimates of prevalence are considered
conservative. Reasons for this underestimate may include differences in diagnostic definitions
and inclusion of persons who fall within the bipolar spectrum but who do not meet DSM-IVTR criteria for bipolar I or bipolar II disorder (166).
The Epidemiologic Catchment Area study reported a mean age at onset of 21 years for bipolar disorder (6). When studies examining age at onset are stratified into 5-year intervals, thepeak age at onset of first symptoms falls between ages 15 and 19, followed closely by ages 20–
24. There is often a 5- to 10-year interval, however, between age at onset of illness and age atfirst treatment or first hospitalization (34, 151). Onset of mania before age 15 has been less wellstudied (167). Bipolar disorder may be difficult to diagnose in this age group because of its
atypical presentation with ADHD (13, 157–163). Thus, the true age at onset of bipolar disorder is still unclear and may be younger than reported for the full syndrome, since there is uncertainty about the symptom presentation in children. Research that follows cohorts ofoffspring of patients with bipolar disorder may help to clarify early signs in children.
Onset of mania after age 60 is less likely to be associated with a family history of bipolar
disorder and is more likely to be associated with identifiable general medical factors, including
stroke or other central nervous system lesion (34, 155, 168).
Evidence from epidemiological and twin studies strongly suggests that bipolar disorder is aheritable illness (164, 169). First-degree relatives of patients with bipolar disorder have significantly higher rates of mood disorder than do relatives of nonpsychiatrically ill comparisongroups. However, the mode of inheritance remains unknown. In clinical practice, a family history of mood disorder, especially of bipolar disorder, provides strong corroborative evidence ofthe potential for a primary mood disorder in a patient with otherwise predominantly psychotic
features.
Likewise, the magnitude of the role played by environmental stressors, particularly early inthe course of the illness, remains uncertain. However, there is growing evidence that environmental and lifestyle features can have an impact on severity and course of illness (170–172).
Stressful life events, changes in sleep-wake schedule, and current alcohol or substance abuse
may affect the course of illness and lengthen the time to recovery (26, 71, 73, 173–175).

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TABLE 6. Summary of Manic and Depressive Symptom Criteria in DSM-IV-TR Mood Disorders
DisorderManic Symptom Criteria

Depressive Symptom Criteria

Major depressive disorder No history of mania or hypomania

History of major depressive episodes(single or recurrent)

Dysthymic disorderNo history of mania or hypomania

Depressed mood, more days thannot, for at least 2 years (but notmeeting criteria for a major
depressive episode)

Bipolar I disorderHistory of manic or mixed episodes

Major depressive episodes typical but
not required for diagnosis

Bipolar II disorder

One or more episodes of hypomania; History of major depressive episodes
no manic or mixed episodes

Cyclothymic disorder

For at least 2 years, the presence ofNumerous periods with depressive
numerous periods with hypomanic symptoms that do not meet criteria
symptoms
for a major depressive episode

Bipolar disorder nototherwise specified

Manic symptoms present, but
criteria not met for bipolar I,
bipolar II, or cyclothymic disorderNot required for diagnosis

V. REVIEW AND SYNTHESIS OF
AVAILABLE EVIDENCE
왘

A. SOMATIC TREATMENTS OF ACUTE MANICAND MIXED EPISODES
In general, the primary goal of treatment for patients experiencing a manic or mixed episode issymptom control to allow a return to normal levels of psychosocial functioning. The rapid control of symptoms such as agitation and aggression may be particularly important for the safetyof the patient and others.

1. Lithium
Lithium has been used for the treatment of acute bipolar mania for over 50 years. Five studies
have demonstrated that lithium is superior to placebo (176–180). Pooled data from these studies reveal that 87 (70%) of 124 patients displayed at least partial reduction of mania with lithium. However, the use of a crossover design in four of these trials (176–179), nonrandom
assignment in two studies (177, 178), and variations in diagnostic criteria and trial duration
limit interpretation of the results of all but one trial (180). Nevertheless, in the only placebocontrolled, parallel-design trial in which lithium served as an active comparator to divalproex,
lithium and divalproex exerted comparable efficacy (180). In active comparator trials, lithium
displayed efficacy comparable to that of carbamazepine (181, 182), risperidone (183), olanzapine (184), and chlorpromazine and other typical antipsychotics (185–190). Among active
comparator trials, however, only three (185, 186, 189) were likely to be of sufficient size to detect
possible differences in efficacy between treatments. Open studies (191–194) and randomized,
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active comparator-controlled studies (195–197) indicate that lithium is likely to be effective fortreatment of pure or elated mania but is less often effective in the treatment of mixed states.
a) Side effects
Up to 75% of patients treated with lithium experience some side effects (41, 198). These side
effects vary in clinical significance; most are either minor or can be reduced or eliminated by lowering the lithium dose or changing the dosage schedule. For example, Schou (199) reported a
30% reduction in side effects among patients treated with an average lithium level of 0.68 meq/
liter compared with those treated with an average level of 0.85 meq/liter. Side effects that appear
to be related to peak serum levels (e.g., tremor that peaks within 1 to 2 hours of a dose) may be
reduced or eliminated by using a slow-release preparation or changing to a single bedtime dose.
Dose-related side effects of lithium include polyuria, polydipsia, weight gain, cognitive
problems (e.g., dulling, impaired memory, poor concentration, confusion, mental slowness),tremor, sedation or lethargy, impaired coordination, gastrointestinal distress (e.g., nausea, vomiting, dyspepsia, diarrhea), hair loss, benign leukocytosis, acne, and edema (200). Side effects
that persist despite dosage adjustment may be managed with other medications (e.g., betablockers for tremor; diuretics for polyuria, polydipsia, or edema; topical antibiotics or retinoic
acid for acne). Gastrointestinal disturbances can be managed by administering lithium withmeals or changing lithium preparations (especially to lithium citrate).
Lithium may cause benign ECG changes associated with repolarization. Less commonly,
cardiac conduction abnormalities have been associated with lithium treatment. Anecdotal reports have linked lithium with other ECG changes, including the exacerbation of existing arrhythmias and, less commonly, the development of new arrhythmias (201).
The most common renal effect of lithium is impaired concentrating capacity caused by reduced renal response to ADH, manifested as polyuria, polydipsia, or both (202, 203). Although the polyuria associated with early lithium treatment may resolve, persistent polyuria(ranging from mild and well tolerated to severe nephrogenic diabetes insipidus) may occur.
Polyuria can frequently be managed by changing to a once-daily bedtime dose. If the polyuria
persists, management includes ensuring that fluid intake is adequate and that the lithium doseis as low as possible. If these measures do not ameliorate the problem, then concurrent administration of a thiazide diuretic (e.g., hydrochlorothiazide at a dose of 50 mg/day) may be helpful. The lithium dose will usually need to be decreased (typically by 50%) to account for theincreased reabsorption induced by thiazides (198). In addition, potassium levels will need tobe monitored, and potassium replacement may be necessary. Amiloride, a potassium-sparing
diuretic, is reported to be effective in treating lithium-induced polyuria and polydipsia (203).
Its advantages are that it does not alter lithium levels and does not cause potassium depletion.
Amiloride may be started at 5 mg b.i.d. and may be increased to 10 mg b.i.d. as needed (204).
Hypothyroidism occurs in 5%–35% of patients treated with lithium. It occurs more frequently in women, tends to appear after 6–18 months of lithium treatment, and may be
associated with rapid cycling (41, 80, 198, 205). Lithium-induced hypothyroidism is not acontraindication to continuing lithium and is easily treated by the administration of levothyroxine (198, 205). In addition to the other signs and symptoms of hypothyroidism, patientswith bipolar disorder are at risk of developing depression or rapid cycling. If these symptoms
occur in the presence of laboratory evidence of suboptimal thyroid functioning, then thyroid
supplementation, discontinuation of lithium, or both should be considered (206–208).
Hyperparathyroidism has also been noted with lithium treatment (209–211).
A small number of case reports have described exacerbation or first occurrences of psoriasis
associated with lithium treatment (212). Some of these patients improved with appropriate dermatologic treatment or when the lithium dose was lowered. In some cases, however, lithium
seemed to block the effects of dermatologic treatment, with psoriasis clearing only after lithium
was discontinued. In addition, patients occasionally experience severe pustular acne that does
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not respond well to standard dermatologic treatments and only resolves once the lithium treatment is discontinued (212). This is in contrast to the more common mild to moderate acne thatcan occur with lithium treatment, which is usually responsive to standard treatments (198).
Approximately 10%–20% of patients receiving long-term lithium treatment (i.e., for morethan 10 years) display morphological kidney changes—usually interstitial fibrosis, tubular atrophy, and sometimes glomerular sclerosis. These changes may be associated with impairmentof water reabsorption but not with reduction in glomerular filtration rate or development ofrenal insufficiency (41, 198, 213–216). Although irreversible renal failure caused by lithium
has not been unequivocally established, there are a number of case reports of probable lithiuminduced renal insufficiency (215, 217, 218). Additionally, several studies have shown that asmall percentage of patients treated with lithium may develop rising serum creatinine concentrations after 10 years or more of treatment (215, 218).
b) Toxicity/overdose
Toxic effects of lithium become more likely as the serum level rises (219). Most patients will
experience some toxic effects with levels above 1.5 meq/liter; levels above 2.0 meq/liter arecommonly associated with life-threatening side effects. For many patients, the therapeutic
range within which beneficial effects outweigh toxic effects is quite narrow, so that small changes
in serum level may lead to clinically significant alterations in the beneficial and harmful effects oflithium. Elderly patients may experience toxic effects at lower levels and have a correspondingly
narrower therapeutic window (138).
Signs and symptoms of early intoxication (with levels above 1.5 meq/liter) include marked
tremor, nausea and diarrhea, blurred vision, vertigo, confusion, and increased deep tendon reflexes. With levels above 2.5 meq/liter, patients may experience more severe neurological complications and eventually experience seizures, coma, cardiac dysrhythmia, and permanentneurological impairment. The magnitude of the serum level and the duration of exposure to ahigh level of lithium are both correlated with risk of adverse effects (219). Therefore, rapid
steps to reduce the serum level are essential. In addition, during treatment for severe intoxication, patients may experience “secondary peaks” during which the serum level rises after a period of relative decline; the clinician must therefore continue to monitor serum levels during
treatment for severe intoxication. The patient with lithium intoxication should be treated withsupportive care (e.g., maintenance of fluid and electrolyte balance), and steps should be taken
to prevent further absorption of the medication (e.g., gastric lavage or, in the alert patient, induction of emesis).
Hemodialysis is the only reliable method of rapidly removing excess lithium from the bodyand is more effective than peritoneal dialysis for this purpose (220). Criteria for the use of hemodialysis in lithium intoxication are not firmly established, and the decision to dialyze musttake into account both the patient’s clinical status and the serum lithium level (219, 221).
When serum lithium levels are below 2.5 meq/liter, hemodialysis usually is unnecessary. The
need for hemodialysis differs in patients who have developed toxicity after an acute overdose
compared with those who have developed gradual toxicity or have an acute overdose superimposed on long-term lithium treatment. In acute poisoning, hemodialysis is generally requiredwith serum lithium levels over 6–8 meq/liter, whereas hemodialysis may be needed with serum
levels over 4 meq/liter in those who have been on long-term regimens of lithium treatment.
Hemodialysis may also be necessary at lower serum levels in patients who are more susceptible
to complications because of underlying illnesses (e.g., cardiac disease, renal impairment). Regardless of serum lithium level, hemodialysis is generally indicated in patients with progressive
clinical deterioration or severe clinical signs of intoxication such as coma, convulsions, cardiovascular symptoms, or respiratory failure (219, 221). Because serum levels of lithium may rebound after initial hemodialysis, repeat dialysis may be needed (219, 222).

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In cases of overdose with sustained-release preparations of lithium, development of toxicity islikely to be delayed, and the duration of toxicity is likely to be prolonged (223, 224). This should
be taken into consideration in decisions about the need for initial or repeat hemodialysis (219).
c) Implementation and dosing
Before beginning lithium treatment, the patient’s general medical history should be reviewed,
with special reference to those systems that might affect or be affected by lithium therapy (e.g.,
renal, thyroid, and cardiac functioning). In addition, pregnancy or the presence of a dermatologic
disorder must be ascertained. Patient education should address potential side effects of lithium
treatment as well as the need to avoid salt-restricted diets or concomitant medications that could
elevate serum lithium levels (e.g., diuretics, angiotensin-converting enzyme inhibitors, nonsteroidal anti-inflammatory drugs, cyclooxygenase-2 inhibitors). Patients should be cautioned, particularly if nephrogenic diabetes insipidus is present, that lithium toxicity might occur withdehydration from environmental heat, gastrointestinal disturbance, or inadequate fluid intake.
Laboratory measures and other diagnostic tests are generally recommended on the basis ofpathophysiological knowledge and anticipated clinical decisions rather than on empirical evidence of their clinical utility. The decision to recommend a test is based on the probability ofdetecting a finding that would alter treatment as well as the expected benefit of such alterations
in treatment. Recommended tests fall into three categories: 1) baseline measures to facilitate
subsequent interpretation of laboratory tests (e.g., ECG, CBC); 2) tests to determine conditions requiring different or additional treatments (e.g., pregnancy, thyroid-stimulating hormone level); and 3) tests to determine conditions requiring alteration of the standard dosage
regimen of lithium (e.g., creatinine level).
On the basis of these considerations, the following procedures are generally recommended
before beginning lithium therapy: a general medical history, a physical examination, BUN andcreatinine level measurement, a pregnancy test, thyroid function evaluation, and, for patientsover age 40, ECG monitoring with rhythm strip. Some authorities also suggest a CBC.
Lithium is usually started in low, divided doses to minimize side effects (e.g., 300 mg t.i.d. or
less, depending on the patient’s weight and age), with the dose titrated upward (generally to serum concentrations of 0.5–1.2 meq/liter) according to response and side effects (225). Lithium
levels should be checked after each dose increase and before the next. Steady-state levels are likely
to be reached approximately 5 days after dose adjustment, but levels may need to be checkedsooner if a rapid increase is necessary (e.g., in the treatment of acute mania) or if toxicity is suspected. As levels approach the upper limits of the therapeutic range (i.e., ≥1.0 meq/liter), theyshould be checked at shorter intervals after each dose increase to minimize the risk of toxicity.
Serum concentrations required for prophylaxis may be, in some cases, as high as those required for treatment of the acute episode. A controlled study by Gelenberg et al. (225) foundthat patients randomly assigned to a “low” lithium level (0.4–0.6 meq/liter) had fewer side effects but more illness episodes than patients in the “standard” lithium group (0.8–1.0 meq/
liter). However, the lithium levels of some of the patients in the low-lithium group decreased
relatively rapidly from their previous treatment levels, a decrease that could have increased theirrisk of relapse. Although the prophylactic efficacy of lithium levels between 0.6 and 0.8 meq/
liter has not been formally studied, this range is commonly chosen by patients and their psychiatrists (226). Despite the lack of formal study, it is likely that for many patients, increases inmaintenance lithium levels will result in a trade-off between greater protection from illness episodes at the cost of an increase in side effects. The “optimal” maintenance level may therefore
vary somewhat from patient to patient. Some patients find that a single, daily dose facilitatestreatment compliance and reduces or does not change side effects.
The clinical status of patients receiving lithium needs to be monitored especially closely.
The frequency of monitoring depends on the individual patient’s clinical situation but generally should be no less than every 6 months for stable patients. The optimal frequency of serum
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level monitoring in an individual patient depends on the stability of lithium levels over time
for that patient and the degree to which the patient can be relied upon to notice and report
symptoms.
In general, renal function should be tested every 2–3 months during the first 6 months oftreatment, and thyroid function should be evaluated once or twice during the first 6 monthsof lithium treatment. Subsequently, renal and thyroid function may be checked every 6 months
to 1 year in stable patients or whenever clinically indicated (e.g., in the presence of breakthrough affective symptoms, changes in side effects, or new medical or psychiatric signs or
symptoms) (198, 214).

2. Divalproex/valproate/valproic acid
Divalproex and its sodium valproate and valproic acid formulations have been studied in four
randomized, placebo-controlled trials: two small crossover trials (227, 228) and two parallelgroup trials (180, 229). All four studies found significantly greater efficacy for valproate compared with placebo, with response rates ranging from 48% to 53%. Secondary analyses (150,
197) of data from the largest parallel-group trial (180) suggested that patients with prominent
depressive symptoms during mania and with multiple prior mood episodes were more likely torespond to acute treatment with divalproex than with lithium. An additional randomized comparison also reported valproate to be more efficacious than lithium among manic patients with
mixed symptoms (195). In patients with acute mania, divalproex was comparable in efficacy tohaloperidol in an open trial (230) and to olanzapine in a randomized, controlled trial (231) inthe reduction of symptoms of mania and psychosis. In contrast, in a second head-to-head comparison trial (232), olanzapine was superior to divalproex in the mean reduction of manic
symptoms and in the proportion of patients in remission at the end of the study.
a) Side effects
Minor side effects of valproate, such as sedation or gastrointestinal distress, are common initially and typically resolve with continued treatment or dose adjustment. In addition, valproate
has a wide therapeutic window. Inadvertent overdose is uncommon, and purposeful overdose
is less likely to be lethal than it is with lithium. However, in rare instances, valproate can cause
life-threatening side effects, and patients must be relied upon to report the often subtle symptoms of these reactions promptly.
Common dose-related side effects of valproate include gastrointestinal distress (e.g., anorexia, nausea, dyspepsia, vomiting, diarrhea), benign hepatic transaminase elevations, osteoporosis (233, 234), tremor, and sedation. Patients with past or current hepatic disease may be
at greater risk for hepatotoxicity (235). Mild, asymptomatic leukopenia and thrombocytopenia
occur less frequently and are reversible upon drug discontinuation. Other side effects that areoften bothersome to the patient include hair loss (236, 237), increased appetite, and weightgain. Persistent gastrointestinal distress associated with valproate can be alleviated by dose reduction, change of preparation (use of the divalproex sodium formulation rather than valproicacid), or by administration of a histamine-2 antagonist (e.g., famotidine or cimetidine) (238–242). Tremor can be managed with dose reduction or coadministration of beta-blockers. Casesof mild, asymptomatic leukopenia (total WBC count >3000/mm3 and polymorphonuclear
leukocyte count >1500/mm3) are usually reversible upon dose reduction or discontinuation.
Similarly, if mild, asymptomatic thrombocytopenia occurs, a decrease in valproate dose willusually restore the platelet count to normal. However, more severe cases of thrombocytopenia
have been reported (243).
The relationship between polycystic ovarian syndrome and valproate treatment is unclear(244–246). One uncontrolled report indicated that 80% of women receiving long-term valproate treatment for epilepsy before the age of 20 had polycystic ovaries or hyperandrogenism(247). Other cross-sectional studies have demonstrated higher rates of polycystic ovaries andTreatment of Patients With Bipolar Disorder

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polycystic ovarian syndrome in women with epilepsy (244–246). However, none of the studies
examined whether the polycystic ovarian syndrome began before or after the development of epilepsy or the initiation of valproate therapy (246). Furthermore, women with bipolar disorder
may differ from women with epilepsy in their rates of polycystic ovarian syndrome independentof treatment. An accurate assessment of risk will require a longitudinal study of women with bipolar disorder before and after initiation of valproate treatment (246). Consequently, although
the risks are unclear, psychiatrists should be aware that polycystic ovarian syndrome may be possible with valproate treatment, and thus patients should be monitored accordingly (244).
Rare, idiosyncratic, but potentially fatal adverse events with valproate include irreversible
hepatic failure, hemorrhagic pancreatitis, and agranulocytosis. Thus, patients taking valproateneed to be instructed to contact their psychiatrist or primary care physician immediately if they
develop symptoms of these conditions.
b) Toxicity/overdose
Valproate has a wide therapeutic window, so unintentional overdose is uncommon (248). Signsof overdose include somnolence, heart block, and eventually coma. Deaths have been reported.
Overdose can be treated with hemodialysis (249, 250).
c) Implementation and dosing
Before initiating valproate treatment, a general medical history should be taken, with special
attention to hepatic, hematologic, and bleeding abnormalities. Results of liver function tests
and hematologic measures should be obtained at baseline to evaluate general medical health.
Data from a number of open trials (230, 251–253) and one randomized controlled trial (254)indicate that divalproex can be administered at a therapeutic initial starting dose of 20–30 mg/
kg per day in inpatients. This strategy appears to be well tolerated and may be more rapidly
efficacious than more gradual titration from a lower starting dose (254). After a serum valproatelevel is obtained, the dose is then adjusted downward to achieve a target level between 50 and
125 mcg/ml.
Among outpatients, elderly patients, or patients who are hypomanic or euthymic, valproate
may be initiated in low, divided doses to minimize gastrointestinal and neurological toxicity.
Valproate should generally be started at 250 mg t.i.d., with the dose increased every few days
as side effects allow (204). Depending upon clinical response and side effects, the dose is thentitrated upward by 250–500 mg/day every few days, generally to a serum concentration of 50–
125 mcg/ml, with a maximum adult daily dose of 60 mg/kg per day (250). Once the patientis stable, valproate regimens can be simplified to enhance convenience and compliance, since
many patients do well with once- or twice-a-day dosing.
Extended-release divalproex, a new formulation that allows for once-a-day dosing, has become available. Bioavailability is approximately 15% lower than the immediate-release formulation (hence usually requiring slightly higher doses), and side effect profiles appear to be better
than that of the immediate-release formulation (255). Demonstration of efficacy in patientswith bipolar disorder is limited to open studies (255–257).
Asymptomatic hepatic enzyme elevations, leukopenia, and thrombocytopenia do not reliably predict life-threatening hepatic or bone marrow failure. In conjunction with careful monitoring of clinical status, educating patients about the signs and symptoms of hepatic andhematologic dysfunction and instructing them to report these symptoms if they occur are essential. Some investigators believe that in otherwise healthy patients with epilepsy receiving
long-term valproate treatment, routine monitoring of hematologic and hepatic function is notnecessary (258). Nevertheless, most psychiatrists perform clinical assessments, including testsof hematologic and hepatic function, at a minimum of every 6 months for stable patients who
are taking valproate (252, 259, 260). Patients who cannot reliably report signs or symptoms of
toxicity need to be monitored more frequently.
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Psychiatrists should be alert to the potential for interactions between valproate and othermedications (261). For example, valproate displaces highly protein-bound drugs from theirprotein binding sites. In addition, valproate inhibits lamotrigine metabolism and more thandoubles its elimination half-life by competing for glucuronidation enzyme sites in the liver(262, 263). Consequently, in patients treated with valproate, lamotrigine must be initiated at
a dose that is less than half that used in patients who are not receiving concomitant valproate.

3. Carbamazepine
Many controlled trials of carbamazepine have been conducted in the treatment of acute bipolar
mania, but interpretation of the results of a number of these studies is difficult because of theconfounding effects of other medications administered as part of study protocols (264). Carbamazepine was superior to placebo in one randomized, crossover trial (265). Carbamazepine
was less effective and associated with more need for adjunctive “rescue medication” than valproate in a randomized, blind, parallel-group trial of 30 hospitalized manic patients (266). Carbamazepine was comparable to lithium in two randomized comparison trials (181, 182) andcomparable to chlorpromazine in two other randomized trials (267, 268).
a) Side effects
Up to 50% of patients receiving carbamazepine experience side effects, and the drug is associated with potentially serious adverse reactions (258, 269, 270).
The most common dose-related side effects of carbamazepine include neurological symptoms, such as diplopia, blurred vision, fatigue, nausea, and ataxia. These effects are usually transient and often reversible with dose reduction. Elderly patients, however, may be more sensitive
to side effects. Less frequent side effects include skin rashes (271), mild leukopenia, mild
thrombocytopenia, hyponatremia, and (less commonly) hypo-osmolality. Mild liver enzyme
elevations occur in 5%–15% of patients. Mild asymptomatic leukopenia is not related to serious idiopathic blood dyscrasias and usually resolves spontaneously with continuation of carbamazepine treatment or with dose reduction. In the event of asymptomatic leukopenia,
thrombocytopenia, or elevated liver enzymes, the carbamazepine dose can be reduced or, in thecase of severe changes, discontinued. Hyponatremia may be related to water retention caused
by carbamazepine’s antidiuretic effect (272). Hyponatremia occurs in 6%–31% of patients, israre in children but probably more common in the elderly, occasionally develops many months
after the initiation of carbamazepine treatment, and sometimes necessitates carbamazepine discontinuation. In addition, carbamazepine may decrease total and free thyroxine levels and increase free cortisol levels, but these effects are rarely clinically significant. Weight gain is also acommon side effect of carbamazepine.
Rare, idiosyncratic, but serious and potentially fatal side effects of carbamazepine include
agranulocytosis, aplastic anemia, thrombocytopenia, hepatic failure, exfoliative dermatitis(e.g., Stevens-Johnson syndrome), and pancreatitis (243, 258, 273–275). Although these side
effects usually occur within 3–6 months of carbamazepine initiation, they have also occurred
after more extended periods of treatment. Routine blood monitoring does not reliably predictblood dyscrasias, hepatic failure, or exfoliative dermatitis. Thus, in addition to careful monitoring of clinical status, it is essential to educate patients about the signs and symptoms of hepatic, hematologic, or dermatologic reactions and instruct them to report symptoms if theyoccur. Other rare side effects include systemic hypersensitivity reactions, cardiac conduction
disturbances, psychiatric symptoms (including sporadic cases of psychosis), and, very rarely, renal effects (including renal failure, oliguria, hematuria, and proteinuria).
b) Toxicity/overdose
Carbamazepine may be fatal in overdose; deaths have been reported with ingestions of morethan 6 g. Signs of impending carbamazepine toxicity include dizziness, ataxia, sedation, andTreatment of Patients With Bipolar Disorder

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diplopia. Acute intoxication can result in hyperirritability, stupor, or coma. The most common
symptoms of carbamazepine overdose are nystagmus, ophthalmoplegia, cerebellar and extrapyramidal signs, impaired consciousness, convulsions, and respiratory dysfunction. Cardiac
symptoms may include tachycardia, arrhythmia, conduction disturbances, and hypotension.
Gastrointestinal and anticholinergic symptoms may also occur. Management of carbamazepine
intoxication includes symptomatic treatment, gastric lavage, and hemoperfusion.
c) Implementation and dosing
A pretreatment evaluation for carbamazepine should include a general medical history andphysical examination, with special emphasis on prior history of blood dyscrasias or liver disease.
Most authorities recommend that the minimum baseline evaluation include a CBC with differential and platelet count, a liver profile (evaluation of LDH, SGOT, SGPT, bilirubin, andalkaline phosphatase), and renal function tests (204). Serum electrolyte levels may also be obtained, especially in the elderly, who may be at higher risk for hyponatremia.
Although doses can range from 200 to 1800 mg/day, the relationships among dose, serum
concentration, response, and side effects are variable. Therefore, the dose should be titrated upward according to response and side effects. In patients over the age of 12, carbamazepine isusually begun at a total daily dose of 200–600 mg, given in three to four divided doses. In hospitalized patients with acute mania, the dose may be increased in increments of 200 mg/day up
to 800–1000 mg/day (unless side effects develop), with slower increases thereafter as indicated.
In less acutely ill outpatients, dose adjustments should be slower, since rapid increases may
cause patients to develop nausea and vomiting or mild neurological symptoms such as drowsiness, dizziness, ataxia, clumsiness, or diplopia. Should such side effects occur, the dose can be
decreased temporarily and then increased again more slowly once these side effects have passed.
While therapeutic serum levels of carbamazepine have not been established for patients withbipolar disorder, serum concentrations established for treatment of seizure disorders (4–12
mcg/ml) are generally applied. Trough levels are most meaningful for establishing an effective
level for a given patient and are conveniently drawn before the first morning dose. Serum levels
should be determined 5 days after a dose change or sooner if toxicity or noncompliance is suspected. Maintenance doses average about 1000 mg/day but may range from 200–1600 mg/day
in routine clinical practice (204). Doses higher than 1600 mg/day are not recommended.
CBCs, platelet measurements, and liver function tests should be performed every 2 weeks
during the first 2 months of carbamazepine treatment. Thereafter, if results of laboratory tests
remain normal and no symptoms of bone marrow suppression or hepatitis appear, bloodcounts and liver function tests should be performed at least every 3 months (204). More frequent monitoring is necessary in patients with laboratory findings, signs, or symptoms consistent with hematologic or hepatic abnormalities. Life-threatening reactions, however, are notalways detected by routine monitoring. The psychiatrist should educate patients about signs
and symptoms of hepatic, hematologic, or dermatologic reactions and instruct patients to report these symptoms if they occur. More frequent clinical and laboratory assessments are needed for those patients who cannot reliably report symptoms.
Psychiatrists should be aware that carbamazepine is able to induce drug metabolism, including its own, through cytochrome P-450 oxidation and conjugation (261, 263, 276). This enzymatic induction may decrease levels of concomitantly administered medications such as
valproate, lamotrigine, oral contraceptives, protease inhibitors, benzodiazepines, and many antipsychotic and antidepressant medications. In addition, carbamazepine has an active epoxide
metabolite and is metabolized primarily through a single enzyme, cytochrome P-450 isoenzyme
3A3/4, making drug-drug interactions even more likely. Consequently, carbamazepine levels
may be increased by medications that inhibit the cytochrome P-450 isoenzyme 3A3/4, such as
fluoxetine, fluvoxamine, cimetidine, and some antibiotics and calcium channel blockers. Thus,in patients treated with carbamazepine, more frequent clinical and laboratory assessments may
be needed with addition or dose adjustments of other medications.
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4. Other anticonvulsantsOxcarbazepine, the 10-keto analog of carbamazepine, was comparable in efficacy to lithium
and haloperidol in two small trials (277, 278). However, these studies lacked sufficient power
to detect possible drug-drug differences. While direct comparisons with carbamazepine instudies of bipolar disorder are lacking, studies of epilepsy suggest that oxcarbazepine may havea lower rate of severe side effects (279) and be well tolerated overall (280), although it has been
associated with clinically significant hyponatremia (281). Moreover, unlike carbamazepine,
oxcarbazepine does not induce its own metabolism (282). However, it may still decrease plasma concentrations of oral contraceptives and dihydropyridine calcium channel blockers, requiring medication change or dose adjustment. (For a more complete review, see the bipolar
disorder treatment algorithm of the Texas Medication Algorithm Project [283].)
Three controlled studies, all with methodological limitations, have evaluated lamotrigine in
the treatment of bipolar mania. In the first trial, 28 patients with bipolar I or bipolar II disorderwere assessed in a double-blind, randomized, crossover series of three 6-week monotherapy trials of lamotrigine, gabapentin, or placebo (284). The response rate for manic symptom improvement, as measured by the Clinical Global Impression Scale for Bipolar Illness, did not
differ significantly among the three treatment groups. However, the low mean Young Mania
Rating Scale scores at baseline, the crossover design, and the small number of subjects may have
limited the findings. In the second study, 16 outpatients with mania, hypomania, or mixed episodes who were inadequately responsive to or unable to tolerate lithium were randomly assigned to lamotrigine or placebo as mono- or adjunctive therapy (285). There were no
significant differences between lamotrigine and placebo groups on changes in Young Mania
Rating Scale scores or response rates. Limitations of this study included the small study groupsize and high (50%) placebo response rate. In the third study, 30 inpatients were randomly assigned to lamotrigine or lithium for 4 weeks (286). Both treatment groups displayed significant
and comparable reductions in manic symptoms from baseline to endpoint. Limitations of thisstudy included lack of a placebo group, small patient group size, and use of relatively low lithium levels (mean plasma concentration of 0.7 meq/liter at study endpoint). Adverse events andimplementation and dosing issues associated with lamotrigine treatment are described in detailin Section V.B.2.c.
Two controlled studies have evaluated the efficacy of gabapentin in the treatment of bipolar
manic symptoms. In the first study (284), there were no significant differences in efficacy between gabapentin monotherapy and placebo in improvement in manic symptoms. The second
controlled trial (287) compared gabapentin with placebo added to lithium, valproate, or bothin 114 outpatients with manic, hypomanic, or mixed symptoms. Both treatment groups displayed a decrease in Young Mania Rating Scale scores from baseline to endpoint, but this decrease was significantly greater in the placebo group.
Finally, one small placebo-controlled trial also suggested efficacy for the anticonvulsant phenytoin in the treatment of mania when added to haloperidol treatment (288).

5. Olanzapine
Olanzapine was superior to placebo in the treatment of acute bipolar mania in two large, multicenter randomized controlled trials. In the first trial (289), olanzapine versus placebo differences did not reach statistical significance until the third week of treatment. In the second study(290), significant reductions in manic symptoms were apparent in olanzapine-treated patientscompared with those receiving placebo at the first assessment point (after 1 week). These differences were probably due to differences in initial starting dose, since the initial olanzapine
dose was 10 mg/day in the first study and 15 mg/day in the second trial. In a secondary analysisof data from the second trial, in which sufficient proportions of patients with mixed episodes
or rapid cycling were included for comparison, olanzapine response was comparable in patientswith or without these features (291). In other randomized, controlled trials, olanzapine exerted
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comparable efficacy to lithium (184), divalproex (231), and haloperidol (292) in the reductionof manic symptoms. Olanzapine was superior to divalproex in a randomized comparison trial(232). Last, olanzapine was superior to placebo as adjunctive therapy to lithium or divalproex
in a randomized, controlled acute treatment trial (292).
a) Side effects
In short-term, placebo-controlled clinical trials, somnolence was the most common side effectassociated with olanzapine. Other common side effects included constipation, dry mouth, increased appetite, and weight gain (291). Especially during initial dose titration, olanzapine may
induce orthostatic hypotension associated with dizziness, tachycardia, and, in some patients,
syncope. Syncope was reported in 0.6% of olanzapine-treated patients in phase II and III trials.
In clinical trials, seizures occurred in 0.9% of olanzapine-treated patients. Although confounding factors may have contributed to seizures in many instances, olanzapine should be
used cautiously in patients with a history of seizure disorder or in clinical conditions associatedwith lowered seizure threshold. Transient elevations in plasma prolactin concentrations werealso observed in short-term trials (293). These elevations typically remained within the normal
physiological range and decreased with continued treatment. Clinically significant hepatictransaminase elevations (≥3 times the upper limit of the normal range) were observed in 2% ofolanzapine-treated patients.
In long-term studies, 56% of olanzapine-treated patients gained >7% of their baseline
weight. In retrospective analyses of patients followed for a median of 2.54 years, the mean andmedian weight gains were 6.26 kg and 5.9 kg, respectively (294). Weight gain did not appear to
be dose related, occurred most rapidly within the first 39 weeks of treatment, was greatest in patients with the lowest baseline body mass index, and was not correlated with increases in serum
glucose. Increases in serum glucose in olanzapine-treated patients did not differ significantly
from those in patients treated with haloperidol (294). Weight gain and hyperglycemia in patients treated with atypical antipsychotics have been reviewed in detail elsewhere (295, 296).
In short-term trials, there were no significant differences in the incidence of dystonic reactions, parkinsonism, akathisia, or dyskinetic events among patients receiving placebo or olanzapine (291). Also, extrapyramidal side effects with olanzapine were substantially less than thoseseen with conventional antipsychotic medications such as haloperidol (297). In a 1-year haloperidol-controlled trial, the incidence of dyskinetic movements among olanzapine-treatedpatients with schizophrenia was 0.6% compared with 7.5% in patients receiving haloperidol(298). This incidence rate is confounded by prior treatment with typical antipsychotics and therate of spontaneous dyskinesia in patients with schizophrenia. In 98 patients with bipolar disorder who received olanzapine for 1 year, some in combination with lithium or fluoxetine, no patients developed dyskinetic movements (291).
b) Implementation and dosing
In the two placebo-controlled studies of olanzapine in patients with bipolar mania, the mean
final dose was approximately 15 mg/day. In the first study in which olanzapine was initiated at
10 mg/day and then titrated according to response and side effects, olanzapine did not differentiate from placebo until the third week of the trial (289). The second trial used a starting
dose of 15 mg/day and found a significant difference in efficacy in favor of olanzapine at 1 week(the time of the first rating) (290). Taken together, the results of these trials suggest that for
inpatients with acute mania, a starting dose of 15 mg/day may be more rapidly efficacious. For
outpatients, lower starting doses of 5–10 mg/day may be indicated (299).

6. Other antipsychotics
Only one randomized, placebo-controlled study of typical antipsychotic medications has beenreported in the treatment of acute bipolar mania (300). In this study, chlorpromazine was su40

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perior to placebo in global improvement of manic symptoms. Typical antipsychotics were comparable to lithium in reducing manic and psychotic symptoms in acute treatment comparison
trials (185–190).
Among the atypical antipsychotic agents, risperidone and ziprasidone have also been studied in the treatment of acute bipolar mania with randomized, placebo-controlled trials. As an
adjunct to treatment with lithium or divalproex, risperidone was comparable to haloperidoland superior to placebo (301). Ziprasidone was also superior to placebo in a large, multicentermonotherapy trial, with significant differences in favor of ziprasidone apparent at the time of
the first rating, day 2 of treatment (302). While no placebo-controlled trials exist for the use of
clozapine in the treatment of bipolar disorder, one randomized 1-year trial in patients with refractory bipolar or schizoaffective disorder showed greater clinical improvement with the addition of clozapine than with treatment as usual (303). An open trial of clozapine in thetreatment of refractory mania was also associated with improvement in manic symptoms (304,305). In general, these trials have used dose ranges similar to those used in schizophrenia trials,
with similar rates of adverse events.

7. Combination therapy
Controlled trials of lithium plus an antipsychotic and of valproate plus an antipsychotic suggest
greater efficacy or more rapid onset of action with these combinations than with any of theseagents alone. All of these studies involved patients who were currently being treated but who
experienced breakthrough episodes of mania or incomplete response to monotherapy. The
studies compared combination therapies: an antipsychotic combined with either valproate orplacebo (306); lithium or valproate combined with either olanzapine or placebo (290); lithiumor valproate combined with either risperidone or placebo (301); or lithium, valproate, or carbamazepine combined with either risperidone or placebo (307). This last trial supported combination therapy only when the carbamazepine-treated group was excluded.

8. ECT
Three prospective studies have assessed clinical outcomes of treatment of acute mania with ECT.
In a prospective, randomized controlled trial (308), patients who received ECT followed by lithium maintenance treatment exhibited greater improvement after 8 weeks than did patients who
received lithium as both acute and maintenance treatment. Clinical outcomes with ECT werealso found to be superior to outcomes with a combination of lithium and haloperidol (309). Ina third study (310), 30 manic patients were all treated with chlorpromazine but were randomly
assigned to receive a course of either six ECT sessions or six sham ECT sessions. Patients treatedwith sham ECT did significantly worse than those treated with real ECT. Although all of thesestudies had small study group sizes, the results were consistent with other earlier retrospective
comparisons of outcome in mania (311, 312) and with earlier naturalistic case series (seeMukherjee et al. [309] and the APA Task Force Report on ECT [110] for reviews).
Although there are no prospective, randomized controlled studies of the use of ECT in thetreatment of mixed states, in the aforementioned trial of ECT for treatment of mania (308),
the strongest predictor of clinical response was the baseline rating of depressive symptoms. Case
reports also suggest that ECT may be efficacious in treatment of mixed states (313–315).
Information on side effects and implementation of ECT can be found in the APA Task
Force Report on ECT (110).

9. Novel treatments
A number of new agents are under active investigation as potential treatments for patients withacute bipolar mania, but data regarding their efficacy from randomized controlled trials are not
yet available. These agents include the atypical antipsychotics quetiapine and aripiprazole; theantiepileptics zonisamide, acamprosate, and levetiracetam; and omega-3 fatty acids (316).
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Two other medication classes, benzodiazepines and calcium channel blockers, have been studied in randomized controlled trials for treatment of acute bipolar mania. Among the benzodiazepines, clonazepam and lorazepam have been studied alone and in combination with lithium(317–322). Interpretation of many of these studies is confounded by small study group sizes,
short treatment durations, concomitant antipsychotic use, and difficulties in distinguishing putative antimanic effects from nonspecific sedative effects. Taken together, however, these studies
suggest that the sedative effects of benzodiazepines may make them effective treatment adjuncts
while awaiting the effects of a primary antimanic agent to become evident. The fact thatlorazepam, unlike other benzodiazepines, is well absorbed after intramuscular injection has madeit particularly useful for the management of agitation. However, intramuscular olanzapine was superior to intramuscular lorazepam in ameliorating agitation in patients with bipolar mania (322).
Two randomized, controlled trials found little support for the efficacy of the calcium channel antagonist verapamil in the treatment of acute mania. In the first study, verapamil was compared with lithium in 40 patients hospitalized for an acute manic episode (323). The mean
reduction in manic symptoms was significantly greater in the group of patients receiving lithium compared with the verapamil-treated group. The second trial, a 3-week double-blind
study involving 32 patients with acute mania (324), showed no significant differences in efficacy between verapamil and placebo. These studies indicate that lithium was superior to verapamil and that verapamil, in turn, was not superior to placebo as an antimanic agent. In
contrast, in a crossover trial involving 12 patients with refractory ultrarapid-cycling bipolar disorder (325), the calcium channel antagonist nimodipine was superior to placebo in ameliorating mood cycling.

왘

B. SOMATIC TREATMENTS OF ACUTE DEPRESSIVE EPISODES
Somatic treatments that have been studied in bipolar depression include lithium, anticonvulsants, antidepressants, and ECT. Open studies and case reports comprise most of the literatureon the treatment of bipolar depression, with the best-controlled data relating to treatment withlithium, lamotrigine, and paroxetine.
In general, the goals for treatment of acute depression in a patient with bipolar disorder are
identical to those for patients with nonbipolar depression. The primary goal is remission of thesymptoms of major depression and a return to normal levels of psychosocial functioning. Concerns about precipitation of a manic or hypomanic episode introduce management issues inthe treatment of bipolar depression that do not exist for unipolar depression. This section will
present efficacy data on lithium, anticonvulsants, antidepressants, ECT, and novel treatments.
Information on side effects and implementation and dosing issues for lithium and the anticonvulsants are presented in this guideline in their respective sections under “Somatic Treatmentsof Acute Manic and Mixed Episodes” (Section V.A). Information on side effects and implementation and dosing issues for the antidepressants is provided in the APA Practice Guideline
for the Treatment of Patients With Major Depressive Disorder (2).

1. Lithium
There have been eight placebo-controlled studies of lithium in the treatment of bipolar depression that had five or more subjects. All of these studies employed crossover designs, and all werecompleted before 1980 (for a review, see Zornberg and Pope [326]). Among a total of 160 patients, the overall rate of response to lithium, regardless of the degree of improvement or relapse
with placebo, was 79%. However, the “unequivocal” lithium response rate, defined as a goodor moderate response to lithium with a subsequent relapse when given placebo, was much lower (36%). An additional consideration in the use of lithium as an antidepressant is its time toonset (6–8 weeks), which is later than its antimanic effect (326).

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2. Anticonvulsantsa) Divalproex and sodium valproate
There have been no published controlled studies of valproate in the treatment of bipolar depression. In an unpublished study, 43 subjects with bipolar I or bipolar II depression were enteredinto an 8-week, double-blind, placebo-controlled trial of divalproex. Forty-three percent of divalproex-treated patients and 27% of placebo-treated patients achieved recovery, defined as an improvement of ≥50% in score on the 16-item Hamilton Depression Rating Scale in the absenceof hypomania (Young Mania Rating Scale score <10). This difference was not statistically significant (Gary Sachs and Michelle Collins, personal communication). While these results suggest that divalproex may be useful in the treatment of bipolar depression, a more definitive
study is needed.
b) Carbamazepine
In a double-blind, placebo-controlled crossover study (327), four of nine patients with bipolar
depression showed significant improvement from baseline in depressive symptoms with carbamazepine treatment.
In an open study of carbamazepine (328), there were significant reductions from baseline in
17-item Hamilton depression scale scores among 27 patients with bipolar depression and ninepatients with mixed episodes. Patients with mixed episodes were significantly less likely to havea remission than those with bipolar depression.
c) Lamotrigine
Lamotrigine at doses of 50 mg/day and 200 mg/day was compared with placebo in a 7-weekdouble-blind trial in 195 patients with bipolar I disorder with major depression (329). Both lamotrigine groups reported significantly better response rates on the Montgomery-Åsberg Depression Rating Scale but not on the Hamilton depression scale. The first significant lamotrigine
versus placebo difference in Hamilton depression scale scores occurred at week 5 in the patients
receiving 200 mg/day, whereas it occurred at week 7 in those given 50 mg/day. Switches into
manic or hypomanic episodes occurred at equivalent rates (3%–8%) among the three groups.
In a flexible-dose, placebo-controlled study of lamotrigine in 206 patients with bipolar I or
bipolar II major depression (330), both treatment groups improved significantly (response rate
to lamotrigine was 50%, response rate to placebo was 49%), but lamotrigine did not distinguish itself from placebo. Lamotrigine was started at 25 mg/day and titrated over 5–6 weeks to
the target dose of 400 mg/day. In a subgroup analysis, the patients with bipolar I disorder given
lamotrigine did respond significantly better than those given placebo in terms of MontgomeryÅsberg Depression Rating Scale score (mean change of 13.5 versus 10.1, respectively).
In a double-blind, crossover study of patients with refractory, rapid-cycling bipolar I or bipolar II disorder who were treated with lamotrigine, gabapentin, or placebo, 45% of the depressed patients responded to lamotrigine, compared with response rates of 26% for gabapentin
and 19% for placebo (284).
Finally, in an open study of patients with refractory bipolar disorder, 48% of 40 depressed
patients treated with lamotrigine showed a marked response, and 20% showed a moderate response (331).
The most common side effects of lamotrigine in the treatment of depression are headache,nausea, infection, and xerostomia (39, 329). However, none of these occurred at significantly
higher percentage than with placebo (332).
The risk of serious rash, including Stevens-Johnson syndrome and toxic epidermal necrolysis,
was found to be higher in patients treated for epilepsy in the first year after the introduction oflamotrigine in Europe (333). In clinical trials for epilepsy, the incidence of serious rash was approximately 0.3% in adults and approximately 1% in children (334, 335). However, with a slow
titration schedule, the risk of serious rash was reduced to 0.01% in adults (329), which is comTreatment of Patients With Bipolar Disorder

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parable to that of other anticonvulsant medications. Rash can occur at any time during treatment
but is more likely to occur early in treatment. It may also be more likely if lamotrigine and valproate are administered concomitantly (334, 335). Whenever lamotrigine is prescribed, patientsshould be apprised of the risk of rash and urged to contact the psychiatrist or primary care physician immediately if a rash occurs. At rash onset, it is difficult to distinguish between a serious
and a more benign rash. Particularly worrisome are rashes accompanied by fever or sore throat,
those that are diffuse and widespread, and those with prominent facial or mucosal involvement.
In such circumstances lamotrigine (and concurrent valproate) should be discontinued.
Lamotrigine should be administered at 25 mg/day for the first 2 weeks, then 50 mg/day forweeks 3 and 4. After that, 50 mg can be added per week as clinically indicated. With concurrent
valproate treatment, pharmacokinetic interactions lead to lamotrigine levels that are approximately twice normal. To minimize the risk of potentially serious rash in patients who are receiving valproate, the dose schedule should be cut in half (i.e., 12.5 mg/day or 25 mg every otherday for 2 weeks, then 25 mg/day for weeks 3 and 4). Similarly, concurrent carbamazepine treatment leads to an increase in lamotrigine metabolism and requires dosing to be doubled. Further
details of lamotrigine dosing and adverse effects can be found in several reviews (262, 334–337).
d) Topiramate
There are no placebo-controlled trials of topiramate in the treatment of bipolar depression, butseveral trials have suggested its efficacy as an add-on therapy. McIntyre et al. (338) conducteda single-blind, add-on study of topiramate and sustained-release bupropion in depressed patients with bipolar I or bipolar II disorder. Both groups had significant baseline-to-endpoint
reduction in 17-item Hamilton depression scale and Clinical Global Impression (CGI) improvement scores, with no difference between the two groups. Thirty-three percent of patients
receiving cotreatment with topiramate discontinued treatment because of adverse events compared with 22% of the patients receiving bupropion alone. The most common adverse eventswere sweating, blurred vision, difficulty sleeping, tremors, and paresthesia.
Hussain (339) conducted an open-label, add-on, 6-month study with topiramate in depressed patients with bipolar I or bipolar II disorder. Of 45 patients, 19 fully responded(Hamilton depression scale score=3–7), and 12 partially responded (Hamilton depression scalescore=8–12). Five patients discontinued treatment because of lack of efficacy, and nine discontinued because of adverse events.
Conversely, in an open study of patients with bipolar I or bipolar II disorder, the 11 patients
who were initially depressed and received add-on topiramate treatment had no significant improvements in either CGI or Inventory of Depressive Symptomatology scores (316).

3. MAOI antidepressantsa) Tranylcypromine
The efficacy of tranylcypromine was compared with that of imipramine in 56 outpatients withbipolar I or bipolar II depression (340). Compared with imipramine (at doses of at least 150
mg/day), tranylcypromine (at doses of at least 30 mg/day) produced significantly superior outcomes in terms of lower attrition, greater symptomatic improvement, and higher global response without a greater risk of treatment-emergent hypomania or mania.
In a second study (341), tranylcypromine was compared with imipramine in a double-blindcrossover fashion for the 16 nonresponsive patients with bipolar I or bipolar II disorder fromthe previous trial. Tranylcypromine had comparatively better results, including lower attrition,
greater symptomatic improvement, higher global response, and no greater risk of precipitatinga switch into hypomania or mania.

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b) Moclobemide
Moclobemide was compared to imipramine in a 4-week, multicenter, randomized study of 381
patients (342). No significant differences in efficacy were observed between the groups (bothhad response rates of 58%). The number of patients with adverse events and the total numberof adverse events were greater in the imipramine group.

4. SSRIs and other newer antidepressant agentsa) Fluoxetine
Fluoxetine was compared with imipramine and placebo in 89 patients with bipolar depression.
Twenty-two of the 89 patients were also taking lithium during the study. Eighty-six percent of
the patients receiving fluoxetine over 6 weeks improved compared with 57% receiving imipramine and 38% given placebo. The response rate with fluoxetine was significantly better thanthat of both imipramine (p<0.05) and placebo (p=0.005). There were significantly fewer fluoxetine patients who discontinued treatment because of adverse events (343).
b) Paroxetine
Paroxetine was studied as an add-on treatment in three double-blind studies of patients withbipolar depression. In one study (344), depressed patients with bipolar I or bipolar II disordermaintained on regimens of lithium or divalproex were randomly assigned either to addition ofparoxetine or a combination of lithium and divalproex in a 6-week outpatient trial. In terms ofimprovement from baseline in 17-item Hamilton depression scale scores, both treatments wereequally effective at week 6: the mean scores of 6 and 9 in the subjects given lithium plus divalproex and those treated with adjunctive paroxetine, respectively, represented a decrease of
50%–70% (p<0.001). There were more dropouts among those treated with the combinationof lithium and divalproex.
In a placebo-controlled multicenter trial of paroxetine and imipramine in the treatment ofpatients with bipolar I depression maintained on a regimen of lithium (345), imipramine andparoxetine were found to be superior to placebo in patients whose serum lithium level was ≤0.8
meq/liter. In those patients with serum lithium levels >0.8 meq/liter, there were no differencesamong the groups. Of the patients receiving imipramine, treatment-induced switches into manic or hypomanic episodes occurred in 6% of those with lithium levels >0.8 meq/liter and 11%of those with lithium levels ≤0.8 meq/liter. Switches occurred in none of the paroxetine-treatedpatients and in 2% of the placebo group (all of whom had lithium levels ≤0.8 meq/liter).
Paroxetine and venlafaxine were studied in the treatment of patients with bipolar depression
on a maintenance medication regimen (346). Forty-three percent of the paroxetine group and
48% of the venlafaxine group were rated as having responded (difference not significant).
Whereas switches to episodes of mania or hypomania occurred in 3% of those treated with paroxetine, the rate of switching in the venlafaxine group was 13%.
c) Citalopram
In a 24-week, open-label trial, the use of citalopram as an add-on treatment was studied in 45
patients with bipolar depression (30 [67%] with bipolar I disorder) who were receiving lithium, valproate, or carbamazepine (347). Of the 33 patients who completed the 8-week acutephase, 64% responded, and most of these patients continued to improve through the 16-weekcontinuation phase.
d) Bupropion
There have been two controlled studies of bupropion in the treatment of bipolar depression.
In a double-blind, 8-week study (348), patients who had been maintained on regimens of lithium, valproate, or carbamazepine were randomly assigned to bupropion or desipramine treatTreatment of Patients With Bipolar Disorder

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ment. The response rate was 55% for bupropion and 50% for desipramine, a nonsignificant
difference. In the first 8 weeks, 30% of the patients receiving desipramine switched into a manic
episode, whereas 11% of those receiving bupropion did. Over the entire study, with follow-up
to 1 year, the observed rate of switching into manic or hypomanic episodes in patients receiving
desipramine was 50%, whereas the rate was 11% with bupropion.
In a 6-week, double-blind study of bupropion versus idazoxan (a selective α2 antagonist) in
16 patients with bipolar I disorder—some of whom were also on a maintenance regimen oflithium—no significant differences were seen between the groups (349).
e) Venlafaxine
In addition to the aforementioned double-blind study that compared venlafaxine with paroxetine (346), another study reported on 15 depressed women with bipolar II disorder who weretreated with venlafaxine (350). Sixty-three percent of the patients experienced a ≥50% reduction from baseline in scores on the 21-item Hamilton depression scale. Two patients (13%) discontinued treatment because of adverse events.

5. Tricyclic antidepressantsImipramine and desipramine have been used as active control treatments in studies of tranylcypromine, fluoxetine, paroxetine, and bupropion. In general, the tricyclic antidepressants had
response rates that were equivalent to or poorer than that of the active comparator (yet superior
to placebo). In addition, treatment with tricyclic antidepressants was associated with higher
rates of switching into manic or hypomanic episodes.

6. Antipsychotics
In an 8-week, double-blind study of olanzapine monotherapy, olanzapine and fluoxetine combination therapy, and placebo in the treatment of 833 patients with acute bipolar I depression,olanzapine monotherapy and combination therapy were both significantly better than placebo
at endpoint (M. Tohen, personal communication, 2001). Furthermore, both of these treatment regimens showed significant separation from placebo at week 1.

7. ECT
Several controlled studies of ECT in patients with bipolar depression were conducted several
decades ago (326). All found ECT to be as or more effective than MAOIs, tricyclic antidepressants, or placebo. ECT is a viable option for patients with severe bipolar depression, especially
if psychotic features are present (110). For information on side effects and implementation of
ECT, see the APA Task Force Report on ECT (110).

8. Novel treatments
Several studies have suggested that sleep deprivation has an antidepressant effect in patientswith bipolar depression, although its effect is usually short-lived (351). It has been studied inconjunction with pindolol in a placebo-controlled protocol (352). Forty patients with bipolar
depression were randomly assigned to receive either pindolol or placebo in combination withtotal sleep deprivation. Fourteen of 20 patients who underwent total sleep deprivation while
receiving pindolol were rated as having responded (Hamilton depression scale score <8), whereas only one patient receiving placebo and pindolol responded. No switches into manic episodes
were observed. Another study examined the value of phototherapy or lithium in conjunction
with total sleep deprivation among 115 patients with bipolar depression (353). The authors
reported that each adjunctive treatment improved total sleep-deprivation response rates, but
the combination of all three added nothing.

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Thyroid hormones, particularly thyroxine (T4), have been reported to be useful in the treatment of bipolar disorder, particularly rapid cycling (205). In patients with nonbipolar depression, triiodothyronine (T3) augmentation is associated with an antidepressant effect. The useof thyroid hormones in patients with bipolar depression remains to be studied.
The use of other agents, such as risperidone, olanzapine, ziprasidone, omega-3 fatty acids(354), pramipexole (355), or interventions such as phototherapy (353), vagus nerve stimulation (356), or repetitive transcranial magnetic stimulation (357) requires further study.

왘C. RAPID CYCLING
Rapid cycling is generally difficult to treat (358, 359). An important first step is to assess forand treat medical conditions that may contribute to cycling, such as hypothyroidism or drugor alcohol use. Medications, particularly antidepressants, may also contribute to cycling. Such
medications should be discontinued if possible. Increases in cycling frequency or precipitationof hypomanic or manic episodes have been reported in association with essentially all currently
approved antidepressants (340, 343, 360). Use of some form of mood chart can aid in identifying a link between a medication and cycling frequency.
Rapid cycling is relatively unresponsive to lithium or carbamazepine (358, 361–363).
Among 41 lithium-treated patients with rapid-cycling bipolar disorder followed for 5 years, allpatients experienced at least one recurrence. Twenty-six percent derived limited or no prophylactic benefit (364). The limited benefit of lithium in rapid cycling may be a function of its lackof efficacy for depressive symptoms, despite its efficacy for manic symptoms (365, 366). In the
open-stabilization phase of a study of lithium and divalproex in patients with rapid-cycling
bipolar disorder, those who failed to meet criteria for random assignment were more likely tohave refractory depression (76%) than manic or mixed states (24%) (40). These results suggestthat 1) the major benefit of treatment with lithium or lithium combined with divalproex is on
the manic aspects of rapid-cycling bipolar disorder and 2) rapid cycling is principally characterized by recurrent depression.
In a randomized, blind, placebo-controlled study of 182 patients with rapid-cycling bipolar
I or bipolar II disorder who were receiving maintenance treatment (39), lamotrigine was superior to placebo on overall study survival (p<0.04) but not on the primary measure, which was
the time elapsed until the onset of a mood episode that required additional pharmacotherapy.
The lamotrigine over placebo advantage was greatest (p=0.01) among the 52 patients with bipolar II disorder: the median time to discontinuation for any reason among patients with bipolar
II disorder was 17 weeks for the patients receiving lamotrigine and 7 weeks for those given placebo (the discontinuation times among the entire group were 18 weeks and 12 weeks for thelamotrigine-treated and placebo-treated patients, respectively). Similarly, the rate of study completion without relapse in patients receiving medication monotherapy was significantly greater
among the lamotrigine-treated than among the placebo-treated patients with bipolar II disorder(46% versus 18%, p=0.04); this difference was not seen among those with bipolar I disorder(39). An open study comparing response to lamotrigine in patients with rapid-cycling versus
non-rapid-cycling bipolar disorder also indicated efficacy, with some evidence that rapid-cycling
patients with more severe manic symptoms at the start of treatment respond less well (367).
Divalproex was effective as monotherapy or as an add-on therapy in an open study of 107
rapid-cycling patients followed for a mean of 17 months. Marked benefit occurred among 77%of the patients who entered the study when manic or hypomanic. However, only 38% of those
who entered the study depressed reached the maintenance stage (368, 369).
These limited data provide support for the use of lamotrigine in rapid-cycling bipolar disorder—especially for depressive features, which appear to dominate the bipolar II form of rapid
cycling—and suggest that combination drug therapy is often superior to use of a single drug.

Treatment of Patients With Bipolar Disorder

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왘

D. MAINTENANCE TREATMENT
Maintenance treatment of patients with bipolar disorder has multiple goals. In addition to relapse
prevention, reduction of subthreshold symptoms, and reduction of suicide risk, aims need to include reduction of cycling frequency and mood instability as well as improvement of functioning.
Maintenance medication is generally recommended following a manic episode (370, 371). Although few studies involving patients with bipolar II disorder have been conducted in this area,
consideration of maintenance treatment for this form of the illness is also strongly warranted.
Maintenance studies pose two difficulties not central to acute episode studies. The multiple
treatment goals make it impractical to select a single goal as an adequate index of efficacy. Also,
because of risks associated with full relapse and of suicidal behavior, few placebo-controlled studies have been conducted, and many of those have enrolled somewhat less severely ill patients
than seen in the spectrum of clinical practice with bipolar disorder (372).
This section will present efficacy data on lithium, anticonvulsants, antipsychotics, and ECT
as maintenance treatment agents. Information on side effects and implementation and dosing
issues for lithium and the anticonvulsants are presented in this guideline in their respective sections under “Somatic Treatments of Acute Manic and Mixed Episodes” (Section V.A), with the
exception of lamotrigine, the data for which are presented under “Somatic Treatment of Acute
Depressive Episodes” (Section V.B.2.c).

1. Lithium
Studies conducted over 25 years ago consistently reported lithium to be more effective thanplacebo with regard to the proportion of patients who did not relapse (373–377). Most of thesestudies used discontinuation study designs, in which patients taking stable doses of lithium
were abruptly discontinued from lithium if randomly assigned to placebo. It has subsequently
become clear that such discontinuation of lithium increases early relapse into mania or depression (378). These studies had additional design limitations, including enrollment of both unipolar and bipolar depressed patients, lack of specification of diagnostic criteria, reporting ofresults only for patients who completed the study, and failure to report reasons for premature
discontinuation. These studies raised expectations for lithium therapy unrealistically.
In large, open, naturalistic studies on the effectiveness of lithium as a maintenance treatment agent in patients with bipolar disorder, good outcomes (e.g., no relapse and only mild
symptoms) were seen in approximately one-third of the subjects (226, 364, 379–382). At a 2year follow-up evaluation, Markar and Mander (379) reported no difference in the rate of hospital readmissions between patients who received lithium and those who did not. Harrow et al.
(380) reported equivalent 1-year outcomes for patients receiving lithium and those not taking
medication, with 40% of patients taking lithium for the year developing manic episodes.
Coryell et al. (381) reported a lower risk of relapse during the first 32 weeks of treatment forpatients taking lithium than for those receiving no prophylactic medication, but no difference
in relapse risk was seen for weeks 33–96. Other large, open studies that have employed varying
methods have reported similar results (226, 364, 383, 384). In general, these studies have also
reported high dropout rates.
However, two recent randomized, double-blind, parallel-group studies have indicated evidence of efficacy for lithium compared with placebo in extending time until a new manic episode (385, 386). Each study enrolled patients who were currently experiencing or recently had
experienced a manic episode. Symptoms were initially controlled through open treatment withmedications (including those to which the subjects would be randomly assigned). Subjects werethen randomly assigned either to treatment with lithium, placebo, or divalproex (385) or treatment with lithium, placebo, or lamotrigine (386). The first study measured the time until 25%
of subjects undergoing 1 year of maintenance lithium treatment suffered recurrent mania. In
this study, lithium extended the time until recurrence by 55% compared with placebo (385).

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In the second study, an 18-month trial that enrolled patients during or shortly after a manic
episode, lithium significantly extended time until intervention for a recurrent manic episoderelative to placebo (p=0.006). The relapse rate into mania was 17% for lithium-treated patients, compared with 41% for placebo-treated patients (386). However, lithium did not significantly extend time until a new depressive episode in either study and tended to worsen
subthreshold depressive symptoms in the first study (385). These two studies were the firstmaintenance studies to use modern methods, enroll patients during an index manic episode, andtaper lithium taken during the open phase for those patients entering the randomized, placebocontrolled maintenance phase. Earlier randomized, placebo-controlled studies and a crossoverstudy also have reported efficacy for lithium with regard to manic, but not depressive, symptoms(362, 365, 366).
A randomized, open 2.5-year study compared lithium maintenance treatment with that ofcarbamazepine (387). The primary efficacy measure, time until hospitalization, did not indicate
a significant difference between the treatments. However, broader secondary analyses, such as
time until relapse or need for concomitant medication, favored lithium (44% versus 67%, p=0.04). Rapid cycling is associated with relatively poor response to lithium (358); however, in asmall prospective study, both rapid-cycling and non-rapid-cycling patients had fewer manic episodes with lithium therapy than did those receiving placebo (365). In addition, one small study
has suggested that combining lithium and carbamazepine improves the proportion of response
among rapid-cycling patients to a rate equivalent to that of non-rapid-cycling patients (362).
Serum-level guidelines are not well established for maintenance treatment with lithium. In clinical settings, doses and serum levels somewhat lower than those employed for treatment of acutemania are generally used (316). One randomized study of high- and low-dose lithium ranges indicated better efficacy for lithium at 0.8–1.0 meq/liter than at 0.4–0.6 meq/liter in the preventionof manic, but not depressed, episodes (225). However, tolerability was much worse at the higher
range. An open study similarly reported rates of rehospitalization lower than those before treatment for the subset of patients whose serum levels were consistently above 0.5 meq/liter (364).

2. Divalproex or valproate
Valproate has been studied in one placebo-controlled, double-blind, randomized trial (385)
and two randomized comparisons with lithium (254, 388). In the placebo-controlled study,
there was no significant difference in the primary efficacy measure (time until development ofany mood episode) among patients treated with divalproex, lithium, and placebo, although
there was a nonsignificant difference favoring divalproex over lithium (p=0.06). Divalproex
was superior to placebo on rate of early termination for any mood episode (24% versus 38%,
respectively; p<0.02), early termination for depression (6% versus 16%; p<0.02), and termination due to failure to adhere to protocol, intercurrent illness, or administrative reasons (16%versus 25%; p<0.02). Early termination for intolerance or noncompliance favored divalproex
over lithium (22% versus 35%, respectively; p<0.03). The divalproex advantage over placebo
was greater in the subset of 149 patients who had received divalproex treatment for their manic
episode during the open period, with rates of early termination for any mood episode of 29%
and 50%, respectively (p<0.04). One randomized, 18-month open study of valproate (formulated as valpromide) versus lithium reported a 20% lower rate of new episodes among valpromide-treated patients than among lithium-treated patients (388). Relative to patients given
lithium, a lower proportion of patients given valpromide had their treatment discontinued because of intolerance or lack of efficacy. Divalproex and lithium were comparably effective in a
1-year, open, naturalistic, longitudinal study that allowed addition of any needed medication(254). Finally, divalproex was effective both as monotherapy and when added to lithium therapy in a large, open maintenance trial of patients with rapid-cycling presentations (368). Thesefindings indicate efficacy and generally good tolerability of divalproex in maintenance treatment, with effectiveness at least comparable to lithium.
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As with lithium, dosing guidelines for maintenance treatment are less evidence-based thanfor acute treatment of mania, and lower levels are sometimes used for maintenance treatment.
A 1-year study of divalproex found an association between higher serum levels and increased
appetite, reduced platelet counts, and reduced WBC counts (371).

3. Lamotrigine
Lamotrigine has been studied in one large, 18-month, randomized, double-blind, placebo-controlled study of patients who had experienced a manic or hypomanic episode within 60 days ofentry into an open treatment phase (386). Patients who improved during the open treatment
phase were randomly assigned to maintenance treatment with lamotrigine, lithium, or placebo.
For the primary outcome measure (time until additional pharmacotherapy required for treatment of a mood episode), both lamotrigine and lithium were superior to placebo (p<0.02 and
p=0.003, respectively). The median time until one-quarter of the patients in each treatmentgroup developed a mood episode was 72 weeks for those given lamotrigine, 58 weeks for thosereceiving lithium, and 35 weeks for those given placebo. On a secondary outcome measure(time until discontinuation for any reason), lamotrigine was superior to placebo, but lithium
was not (p=0.03 and p=0.07, respectively). Lamotrigine did not significantly prolong the time
until a manic episode but was superior to placebo in prolonging the time until a depressive episode (p<0.02), whereas lithium was not (p<0.17). Lamotrigine was also superior to placebo in
a 26-week study of rapid-cycling patients with bipolar I or bipolar II disorder (39). The primary efficacy measure, time until additional medication required for treatment of a mood episode,did not differ significantly (p=0.07). However, among patients with bipolar II disorder, the median time until additional pharmacotherapy was required was significantly greater for thosereceiving lamotrigine than for those given placebo (17 weeks versus 7 weeks, p=0.01). Timeuntil additional pharmacotherapy was required did not differ significantly among patients withbipolar I disorder. Also, the proportion of patients who completed the study without requiring
additional medication was greater among those treated with lamotrigine than for those given
placebo (41% versus 26%, p=0.03). Among patients requiring additional pharmacotherapy,
80% required medication for depressive symptoms; 20% required medication for manic, hypomanic, or mixed symptoms (39). These results are consistent with those of an open study ofpatients with bipolar disorder treated with lamotrigine for up to 48 weeks either as monotherapy
or as part of combination therapy (329).

4. Carbamazepine
The effectiveness of carbamazepine for maintenance treatment of bipolar disorder is unclear(362). Carbamazepine was inferior to lithium on most outcome measures in one randomized,
open, 2.5-year study (387). Carbamazepine was nonsignificantly better than lithium among
patients with mood-incongruent illnesses, comorbidity, mixed states, and bipolar II disorder(389). Crossover studies have reported carbamazepine somewhat less effective than lithium inmaintenance treatment of bipolar disorder (362, 390). The proportion of time spent in a manic
episode dropped from 25% before treatment to 19% in patients treated with carbamazepine
and 9% in patients treated with lithium (p<0.01). The proportion of time spent in a depressive
episode did not change after initiation of either drug (before treatment: 32%, in patients treated with carbamazepine: 26%, in patients treated with lithium: 31%) (362).

5. Antipsychotic medications
The one placebo-controlled study of prophylactic treatment with an antipsychotic drug did notshow an advantage of flupentixol plus lithium compared with lithium alone (391). Open casereports and one randomized, open study of clozapine plus usual care compared with usual carealone have indicated benefits of maintenance clozapine treatment over 1 year (303).
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6. ECTThe use of ECT on a maintenance basis to prevent mood episodes in patients with bipolar disorder was initially described over 50 years ago (392, 393). While efficacy of maintenance ECTfor bipolar disorder patients has never been assessed in a randomized, controlled trial, multiple
case reports and case series have suggested its utility (51, 356, 394–403). A more extensive naturalistic review (404) identified 56 patients, including nine with bipolar disorder, who received
maintenance ECT following successful index treatment. Of the patients with bipolar disorder,
78% showed at least some improvement, and 33% were much improved.
Vanelle et al. (405) prospectively followed 22 medication-resistant or medication-intolerant
patients for more than 18 months of maintenance ECT treatment. Seven of these individuals
were diagnosed with bipolar disorder, and four had shown a rapid-cycling course. When the
study period was compared with the 1-year period before ECT initiation, the maintenance
ECT group as a whole showed a significant decrease in time spent in the hospital and in thenumber of episodes of illness that necessitated hospitalization. For the patients with bipolar disorder, as well as in those with major depressive disorder, the mean number of mood episodes
significantly decreased during the maintenance ECT course. None of the bipolar disorder patients failed to show a response to maintenance ECT.
Schwarz et al. (406), using a case-control approach, compared depressed patients who responded to an acute course of ECT and then received maintenance ECT to patients who responded to acute ECT but received no maintenance ECT. A third comparison group received
only pharmacotherapy. In each group, four of the 21 patients had a diagnosis of bipolar disorder. Although this number was too small to permit subgroup analysis, the rate of rehospitalization decreased by 67% for the study patients as a whole with implementation of maintenance
ECT. In depressed patients who had responded to an acute course of ECT, Gagné et al. (407)also used a case-control approach to compare patients who received maintenance pharmacotherapy alone with those who received maintenance ECT in combination with maintenancepharmacotherapy. The two groups differed only in the number of “adequate” pharmacotherapy
trials before ECT, with patients receiving maintenance ECT showing greater resistance to pharmacotherapy. Of the 58 depressed patients in the study, 12 had a diagnosis of bipolar disorder.
For the group as a whole, patients receiving maintenance ECT had a greater cumulative probability of surviving without relapse or recurrence at 2 years than patients receiving only pharmacotherapy after the index ECT course (93% versus 52%, respectively). At 5 years, thedifference in survival between the two groups was even more striking (73% versus 18%, respectively). Proportional hazards regression did not demonstrate statistically significant rate differences between patients with bipolar disorder and those with major depressive disorder.
Thus, in studies of maintenance ECT, study group sizes have been small, and patients withbipolar disorder have made up a small proportion of those groups, making subgroup analyses
impossible. Nonetheless, the findings suggest that maintenance ECT may be helpful for individual patients with severe bipolar illness who are unable to tolerate or do not respond to maintenance pharmacotherapy.

왘

E. PSYCHOSOCIAL INTERVENTIONS
Although psychiatric management and pharmacotherapy are essential components of bipolar disorder treatment, specific forms of psychotherapy also are critical components of the treatment planfor many patients. Patients with bipolar disorder suffer from the psychosocial consequences of past
episodes, the ongoing vulnerability to future episodes, and the burdens of adhering to a long-term
treatment plan that may involve unpleasant side effects. In addition, many patients have clinicallysignificant residual symptoms or mood instability between major episodes. The primary goals of
psychotherapeutic treatments are to reduce distress and improve the patient’s functioning between
episodes as well as decrease the likelihood and severity of future episodes (408).
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Most patients with bipolar disorder struggle with some of the following issues: 1) emotional
consequences of episodes of mania and depression; 2) coming to terms with having a potentially chronic mental illness; 3) problems associated with stigmatization; 4) delays or major
deviations in development; 5) fears of recurrence and consequent inhibition of more autonomous functioning; 6) interpersonal difficulties, including issues pertaining to marriage, family,
childbearing, and parenting; 7) academic and occupational problems; and 8) other legal, social,and emotional problems that arise from reckless, inappropriate, withdrawn, or violent behavior
that may occur during episodes. Although a specific psychotherapeutic approach (in addition
to psychiatric management) may be needed to address these issues, the form, intensity, and focus of psychotherapy will vary over time for each patient.
There are now a range of specific psychotherapeutic interventions that have been shown tobe helpful when used in combination with pharmacotherapy and psychiatric management fortreatment of bipolar disorder. The best-studied treatment approaches have been developedaround psychoeducational, interpersonal, family, and cognitive behavior therapies. Formal
studies have been conducted for these treatments, and additional investigations are underway.
Further, psychodynamic and other forms of therapy may be indicated for some patients. The
available psychotherapeutic treatments are discussed as separate entities, even though psychiatrists commonly use a combination or synthesis of different approaches depending on bothtraining and the patient’s needs and preferences.

1. Efficacy
Evidence concerning the utility of specific psychosocial interventions for patients with bipolar
disorder is slowly building. The research summarized here involves the specific forms of psychotherapy that have been studied in randomized, controlled clinical trials.
Perry et al. (27) evaluated a relatively brief (average: seven sessions) individual psychoeducational intervention that focused on illness management, recognition of risk factors, and prevention of
relapses. When compared with a group randomly assigned to a treatment-as-usual condition, patients receiving psychoeducation (in addition to pharmacotherapy) experienced a significant reduction in risk of manic relapses as well as improved social and vocational functioning.
A brief (approximately six sessions) inpatient family intervention (409) has been developed
for patients with schizophrenia or bipolar disorder. Goals include accepting the reality of theillness, identifying precipitating stressors and likely future stressors inside and outside the family, elucidating family interactions that produce stress on the patient, planning strategies for
managing or minimizing future stressors, and bringing about the patient’s family’s acceptanceof the need for continued treatment after hospital discharge. In the initial study (410), the family intervention resulted in improved outcomes for female patients with affective disorders but
not for male patients. In a subsequent study by this group (410), ongoing couples therapy (extending for up to 11 months after hospitalization) was found to significantly enhance treatment adherence and improve global functioning. Unfortunately, this study was too small(intent-to-treat N=42) to reliably detect more modest effects, such as a reduction of relapse risk.
When the functional impairments of bipolar disorder are severe and persistent, other services
may be necessary, such as case management, assertive community treatment, psychosocial rehabilitation, and supported employment. These approaches, which have traditionally been studied inpatients with schizophrenia, also show effectiveness for certain individuals with bipolar disorder.
Family-focused treatment was developed for patients who have recently had an episode of mania or depression (411). Family-focused therapy is behaviorally based and includes psychoeducation, communication skills training, and problem-solving skills training. One adequately sized trialof behavioral family treatment has been completed; the investigators found that behavioral family
management (in concert with adequate pharmacotherapy) resulted in a substantial decrease in depressive relapse rates when compared with a treatment-as-usual control condition (412).

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A cognitive behavior therapy program for patients with bipolar disorder has been developedby Basco and Rush (413). The goals of the program are to educate the patient regarding bipolar
disorder and its treatment, teach cognitive behavior skills for coping with psychosocial stressors
and attendant problems, facilitate compliance with treatment, and monitor the occurrence andseverity of symptoms. A large study of the impact of cognitive behavior therapy for prophylaxis
against bipolar recurrences is underway. Preliminary studies suggest that this approach may
help reduce depressive symptoms (414), improve longer-term outcomes (415), and improvetreatment adherence (416).
The observation that many patients with bipolar disorder experience less mood lability
when they maintain a regular pattern of daily activities (including sleeping, eating, physical activity, and emotional stimulation) has led to the development of a formalized psychotherapy
called interpersonal and social rhythm therapy (417). This form of psychotherapy builds upon
the traditional focus of interpersonal psychotherapy by incorporating a behavioral self-monitoring program intended to help patients with bipolar disorder initiate and maintain a lifestylecharacterized by more regular sleep-wake cycles, meal times, and other so-called social zeitgebers. The ultimate goal is to help regulate circadian disturbances that may provoke or exaggerate episodes of mood disorder.
Frank and colleagues have reported several findings from their ongoing study of interpersonal and social rhythm therapy. First, interpersonal and social rhythm therapy (in combination with pharmacotherapy) was associated with significant increases in targeted lifestyle
regularities when compared with a clinical management plus pharmacotherapy control group(418). However, interpersonal and social rhythm therapy was not associated with a faster time
to recovery from manic (419) or depressive (420) episodes. The withdrawal of interpersonaland social rhythm therapy after stabilization was associated with a significant increase in relapse
rates (421). Across 2 years of maintenance treatment, interpersonal and social rhythm therapy
led to a reduction of both depressive symptoms and manic/hypomanic symptoms and an increase in days of euthymia when compared with treatment as usual (unpublished 2001 study
by E. Frank and D.J. Kupfer).
Finally, preliminary results of a trial comparing group psychoeducation to standard medical carealone among a group of patients with bipolar disorder suggest that patients receiving psychoeducation had significantly fewer manic episodes, depressive episodes, and hospitalizations (422).

2. Psychotherapeutic treatment of mania
Psychosocial therapies alone are generally not useful treatments for acute mania. Perhaps the
only indications for psychotherapy alone are when all established treatments have been refused,
involuntary treatment is not appropriate, and the primary focus of therapy is focused and crisisoriented (e.g., resolving ambivalence about taking medication). In one study of bipolar I disorder patients with acute mania or hypomania, treatment with the combination of interpersonal and social rhythm therapy and pharmacotherapy did not produce an additive effect on
manic symptoms or reduce time to remission when compared with an intensive clinical paradigm plus medication (419). Moreover, patients withdrawn from this psychotherapy after
completion of acute treatment had a poorer prognosis when compared with those who either
received monthly maintenance psychotherapy sessions or recovered with intensive clinicalmanagement and pharmacotherapy (421).

3. Psychotherapeutic treatment of depression
Several psychotherapeutic approaches, including cognitive behavior therapy (423) and interpersonal therapy (424–426), have demonstrated efficacy in patients with unipolar depression, either
in lieu of or in addition to pharmacotherapy. Efficacy data are discussed in the APA Practice
Guideline for the Treatment of Patients With Major Depressive Disorder (2).

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For unipolar depression, the application of a specific, effective psychotherapy in lieu of pharmacotherapy may be considered for patients with mild to moderate symptoms. For bipolar depression, the use of focused psychotherapy instead of antidepressant pharmacotherapy has
potential appeal, particularly with respect to avoiding antidepressant side effects and minimizing
the risk of treatment-emergent mania or induction of rapid cycling. However, only a handful ofreports have described such an approach, and there have been no definitive studies to date.
Cole et al. (420) evaluated the impact of a modified form of interpersonal psychotherapy aspart of a larger study relating thyroid function to clinical course in 65 patients with bipolar I depression. Patients were randomly assigned to receive weekly interpersonal and social rhythm therapy sessions or treatment as usual. All patients received pharmacotherapy (principally lithium
salts); about two-thirds of the patients also received antidepressants. Cole et al. found that theaddition of weekly psychotherapy did not enhance depressive symptom reduction or accelerate
time to remission in comparison with treatment as usual across up to 6 months of treatment.
Zaretsky et al. (414) treated 11 patients with bipolar depression with individual cognitive
behavior therapy (20 weekly sessions) in addition to ongoing pharmacotherapy. They compared their patients’ outcomes to a contemporaneous group of age and sex-matched patientswith unipolar depression. Among the eight completers in the bipolar depression group (sevenwith bipolar I disorder, one with bipolar II disorder), improvements were comparable to thosein the unipolar depression group. Further, no depressed patient receiving cognitive behavior
therapy developed treatment-emergent mania or hypomania.

4. Maintenance treatment
Since the 1994 publication of the first APA practice guideline for bipolar disorder (5), a number of reports on the value of concomitant psychosocial treatment during the maintenancephase of treatment for bipolar disorder have been published. All studies used “add-on” designs,
with patients continuing pharmacotherapies such as lithium and divalproex. Many of these reports described preliminary or pilot studies; nevertheless, results of three larger, more definitive
studies have been published for psychoeducation (27), interpersonal and social rhythm therapy(427), and family-focused (412) interventions.
Overall, these studies demonstrated that the addition of a time-limited individual psychosocial intervention appropriately modified for bipolar disorder is likely to improve outcomes
across 1–2 years of follow-up. When feasible, group psychoeducational interventions also appear useful (428), which may improve the cost efficiency of treatment. Despite these promising
results, however, improvements have not been consistently documented across studies on thefull range of syndromal, functional, adherence, and interpersonal domains. On the basis of amethodological review of the more numerous studies of unipolar depression (429), such inconsistencies in findings are more likely to be attributable to differences in patient populations andstatistical power than true therapeutic specificity.
Nevertheless, the weight of the evidence suggests that patients with bipolar disorder are likely
to gain some additional benefit during the maintenance phase from a concomitant psychosocial
intervention, including psychotherapy, that addresses illness management (i.e., adherence, lifestyle changes, and early detection of prodromal symptoms) and interpersonal difficulties. The
more commonly practiced supportive and dynamic-eclectic therapies have not been studied in
randomized, controlled trials as maintenance treatments for patients with bipolar disorder.

5. Addressing comorbid disorders and psychosocial consequences
Patients in remission from bipolar disorder suffer from the psychosocial consequences of past
episodes and ongoing vulnerability to future episodes. In addition, patients with this disorderremain vulnerable to other psychiatric disorders, including, most commonly, substance use disorders (66) and personality disorders (430, 431). Each of these comorbid disorders has particularconsequences and increases the overall psychosocial vulnerability of the patient with bipolar dis-54

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order. Psychosocial treatments, including psychotherapy, should address issues of comorbidity
and complications that are present.

왘

F. SOMATIC THERAPIES FOR CHILDREN AND ADOLESCENTS
To date, there has been only one double-blind, placebo-controlled, randomized study of pharmacotherapy in the treatment of adolescents with bipolar disorder (432). The majority of information available about pharmacological treatments for bipolar disorder in youth relies upon
open studies, case series, and case reports.

1. Lithium
There are more data available for lithium than for any other medication in the treatment of
bipolar disorder in children and adolescents. Geller et al. (432) conducted the only doubleblind, placebo-controlled, parallel-group study of lithium treatment in 25 adolescent outpatients with comorbid bipolar disorder and substance dependence. Subjects were randomly assigned to lithium or placebo for a 6-week trial. There was significantly greater improvement inglobal functioning with lithium treatment than with placebo. Significantly more patients in thelithium-treatment group experienced thirst, polyuria, nausea, vomiting, and dizziness.
In four double-blind, placebo-controlled, crossover studies of children with bipolar disorder,
significant improvement in mood lability, explosive outbursts, aggressive behavior, and psychosis
was found with lithium compared with placebo (433–436). However, small study group sizes,
diagnostic issues, and short treatment durations limit the interpretation of these findings.
There have also been open studies, case series, and case reports with clinical responses ranging
from 50% to 100% (437–455).

2. Valproate/divalproex
There have been no placebo-controlled studies of divalproex in the treatment of bipolar disorder in children and adolescents, but divalproex response rates in four open studies ranged from
60% to 83% (127, 456–458).
In the only multisite open study of divalproex treatment for children and adolescents withbipolar disorder (458), 40 subjects ages 7–17 years received divalproex for 2–8 weeks. Sixtyone percent of the subjects showed a ≥50% improvement from baseline scores on the Young
Mania Rating Scale. Twenty-three patients (58%) discontinued the study, of whom 16 had acomorbid psychiatric diagnosis such as ADHD, conduct disorder, or oppositional defiant disorder. The most commonly occurring side effects (>10% incidence) were headache, nausea,
vomiting, diarrhea, and somnolence. No significant laboratory abnormalities were noted.
There have also been four case reports or series of divalproex sodium treatment of bipolar
disorder in youth. Response rates have ranged from 66% to 100% in these reports (459–462).
Divalproex also showed efficacy in an active-comparator study in which 42 children and adolescents (ages 8–18 years) with bipolar disorder were randomly assigned to 6 weeks of open
treatment with lithium, divalproex, or carbamazepine (463). No significant differences in response rates (>50% change from baseline to last Young Mania Rating Scale score) were foundamong the patients receiving divalproex (53%), lithium (38%), or carbamazepine (38%).
There were no serious adverse events reported with any of these medications.
In the continuation phase of this study, 35 patients received open treatment for an additional
16–18 weeks (463). Response during the continuation phase was defined as a score of 1 or 2 on
the Bipolar Clinical Global Improvement Scale. Thirty patients (85%) were classified as having
responded at the end of the continuation phase. Only 13 patients (37%) were receiving a single
study drug (lithium, divalproex, or carbamazepine) and no other psychotropic medication at theend of the continuation phase. For the 22 patients who required additional psychotropic medication, 11 received a second study drug (lithium, divalproex, or carbamazepine), and 11 received
a stimulant.
Treatment of Patients With Bipolar Disorder55

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3. Carbamazepine
Information about the use of carbamazepine in the treatment of adolescent bipolar disorder islimited to case reports. Woolston (464) described three cases of carbamazepine monotherapy
for adolescents with bipolar disorder in whom clinical improvement of manic symptoms wasdemonstrated. A positive response was reported with the combination of carbamazepine andlithium in seven adolescents with bipolar disorder (192, 449).

4. Atypical antipsychotics
There are two case series and one open trial of olanzapine as primary or adjunctive treatment
for children and adolescents with bipolar disorder. In an open study, 23 children ages 5–14
years with bipolar disorder received olanzapine 2.5–20 mg/day for 8 weeks (465). Response
was defined as ≥30% improvement in score on the Young Mania Rating Scale, and the response
rate was 61%. There were no significant side effects reported except weight gain (mean=5 kg).
In case reports of three youths (ages 9–19 years) with bipolar disorder, olanzapine was used as
an adjunctive treatment in addition to existing medication regimens (466). Within a week,
CGI scores were rated markedly improved. Sedation and weight gain were the common side
effects. Finally, in a report of seven cases of adolescents with bipolar disorder (467), olanzapine
was used as adjunctive treatment to existing psychotropic medication regimens. Seventy-one
percent of adolescents showed marked to moderate response on CGI scores with adjunctive
olanzapine treatment.
A retrospective chart review of 28 outpatient children and adolescents ages 4–17 years withbipolar disorder assessed adjunctive risperidone treatment (468). These subjects received risperidone over an average of 6 months. Improvement (CGI score ≤2) in manic and aggressive
symptoms was seen in 82% of the patients, and 69% exhibited improvement in psychotic
symptoms. No serious adverse effects were reported, although common side effects were weightgain and sedation.

5. Newer antiepileptics
There are few reports of the use of the newer antiepileptic agents in the treatment of children
and adolescents with bipolar disorder. In a retrospective study of 18 adolescents for whom prior
medication trials had failed (469), subjects with bipolar disorder not otherwise specified (N=15), bipolar II disorder (N=1), or schizoaffective disorder (N=2) received gabapentin at doses
between 900 and 2400 mg/day. Sixteen of the adolescents who continued gabapentin treatment had cessation of cycling. Of these patients, six reported improved mood. Gabapentin was
also reported to be effective in the treatment of an adolescent patient with mania (470).

6. ECT
ECT has been used to treat refractory mania in two prepubertal children (471). A review ofliterature on ECT use in young people (472) reported its efficacy for mania in adolescents.

PART C:
FUTURE RESEARCH NEEDS
While a number of large, double-blind, controlled trials in bipolar disorder have been conductedsince the publication of the first guideline on the treatment of bipolar disorder in 1994 (5),many significant questions remain regarding optimal use of the available treatments. The introduction of new pharmacotherapies, including newer anticonvulsants and atypical antipsychot56

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ics, has also led to a need to directly compare traditional and newer interventions. Moreover,fundamental questions remain to be addressed about the nature of bipolar disorder itself.

VI. GENERAL PRINCIPLES
1. Is there a more clinically and scientifically useful definition of a “mood stabilizer”? Do newer
agents (e.g., atypical antipsychotics and anticonvulsants) have true “mood-stabilizing”
properties?
2. What is the relationship of bipolar I disorder, bipolar II disorder, and possible “bipolar
spectrum” illnesses?
3. To what extent do patients with bipolar I or bipolar II disorder respond differentially totreatment?

VII. ACUTE TREATMENT
왘A. MANIC AND MIXED EPISODES
1. What medication dosage and treatment duration can be considered an adequate trial?
2. In what circumstances is combination therapy favored over monotherapy?
3. Do different atypical antipsychotics exert different antimanic effects? Which combinations are most efficacious?
4. Can true antimanic properties of medications be distinguished from sedative propertiesof medications?

왘B. DEPRESSIVE EPISODES
1. How effective are newer antidepressants, such as SSRIs, in treating bipolar depression?
How and when can they best be combined with other pharmacotherapies, such as lithium
and valproate?
2. Do the different antidepressants have different relative efficacies?
3. What medication dosage and treatment duration can be considered an adequate trial?
4. In treating an episode of bipolar depression, at what point in time is the addition of anantidepressant appropriate?

왘

C. RAPID CYCLING
1. Which pharmacotherapy regimens are most effective in the treatment of rapid cycling?
2. Do newer antidepressants or other medications truly differ in their propensity to induce
rapid cycling or switches into hypomanic episodes?

Treatment of Patients With Bipolar Disorder

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VIII. MAINTENANCE TREATMENT
1. What is the efficacy of newer agents in maintenance pharmacotherapy?
2. What are the predictors of response or nonresponse to maintenance pharmacotherapy?
3. What is the optimum treatment of residual or subthreshold symptoms?
4. How can the side effects seen with all maintenance pharmacotherapies be minimized?
5. To what extent do interventions in bipolar disorder improve functional status rather thansymptoms?

IX. PSYCHOSOCIAL INTERVENTIONS
1. What are the relative efficacies of (and indications for) different psychotherapeutic
approaches in the acute and maintenance phases of treatment?
2. What are the elements of psychotherapy that are critical to its efficacy?

APPENDIX 1. Educational Sources for Depression and Bipolar DisorderInternet Mental Healthwww.mentalhealth.org
National Alliance for the Mentally Ill
Colonial Place Three, 2107 Wilson Blvd.
Suite 300
Arlington, VA 22201(703) 524-7600
NAMI HelpLine: (800) 950-NAMI [6264]
www.nami.org
National Depressive and Manic-Depressive
Association
730 N. Franklin St., Suite 501
Chicago, IL 60610-7204(312) 642-0049(800) 826-3632
www.ndmda.org

58

National Foundation for Depressive Illness, Inc.
P.O. Box 2257
New York, NY 10116(800) 239-1265
www.depression.org
NIMH Public Inquiries
Depression Information Program
6001 Executive Blvd., Rm. 8184
MSC 9663
Bethesda, MD 20892-9663(301) 443-4513
TTY Line: (301) 443-8431
www.nimh.nih.gov
National Mental Health Association
1021 Prince St.
Alexandria, VA 22314-2971(703) 684-7722
TTY Line: (800) 433-5959
www.nmha.org

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INDIVIDUALS AND ORGANIZATIONSTHAT SUBMITTED COMMENTS
Martin Alda, M.D.
Michael H. Allen, M.D.
Jay D. Amsterdam, M.D.
Ross Baldessarini, M.D.
Joseph Biederman, M.D.
Jack Bonner, M.D.
M.L. Bourgeois, M.D.
Joseph Calabrese, M.D.
James E. Campbell, M.D.
Gabrielle A. Carlson, M.D.
Norman A. Clemens, M.D.
Greg Crosby, M.A., L.C.P., C.G.P.
Dave M. Davis, M.D.
Diana L. Dell, M.D.
Himasiri De Silva, M.D.
David L. Dunner, M.D.
Anita S. Everett, M.D.
Ellen Frank, Ph.D.
Valentim Gentil, M.D., Ph.D.
S. Nasir Ghaemi, M.D.
William M. Greenberg, M.D.
Joseph F. Hagan, M.D.
William Hankin, M.D.
Kay Redfield Jamison, M.D.

David Janowsky, M.D.
Gordon Johnson, M.D.
Tadafumi Kato, M.D.
Matcheri S. Keshavan, M.D.
Edward Kim, M.D.
David J. Kupfer, M.D.
Mario Maj, M.D.
John C. Markowitz, M.D.
Theresa Miskimen, M.D.
Rodrigo A. Muñoz, M.D.
Jim Nininger, M.D.
Willem Nolen, M.D.
Herb Peyne, M.D.
June Powell, M.D.
Lawrence H. Price, M.D.
Marian Scheinholtz, M.S., O.T.R.L.
Robert Stern, M.D., Ph.D.
Nada Stotland, M.D., M.P.H.
Stephen M. Strakowski, M.D.
Mauricio F. Tohen, M.D., Ph.D.
Eduard Vieta, M.D., Ph.D.
Myrna Weissman, Ph.D.
Barbara Yarn, M.D.

American Academy of Family Physicians
American Academy of Pediatrics
American College of Obstetricians and Gynecologists
American Group Psychotherapy Association
American Occupational Therapy Association
Brain Science Institute
New Jersey Psychiatric Association

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The following coding system is used to indicate the nature of the supporting evidence in thereferences:[A]

Randomized clinical trial. A study of an intervention in which subjects are prospectively
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Treatment of Patients With Bipolar Disorder

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for reuse, visit APPI Permissions & Licensing Center at http://www.appi.org/CustomerService/Pages/Permissions.aspx.

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[C] Cohort or longitudinal study. A study in which subjects are prospectively followed overtime without any specific intervention.
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for reuse, visit APPI Permissions & Licensing Center at http://www.appi.org/CustomerService/Pages/Permissions.aspx.

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