Pharmacological management of bipolar disorder

Abstract

Background Bipolar disorder is a chronic recurrent neuropsychiatric disorder. The management of the different phases of the illness requires different combinations of medicines and other treatment strategies. Aims To synthesize the current evidence for management of bipolar disorder. Methods We searched the MEDLINE, Cochrane database of systematic reviews and the Database of Abstracts of Reviews of Effects (DARE) for recent systematic reviews and meta-analysis between 1995 and 2010. Original articles of relevant randomised controlled trials (RCT) were accessed. Results and conclusions For treatment of acute mania lithium, valproate and carbamazepine are more effective than placebo but they have no superiority over antipsychotics. There is evidence from RCTs that second generation antipsychotics (SGA) are more effective than placebo. Haloperidol may be more effective than SGA in treatment of acute mania. Combination of antipsychotic and mood stabiliser is more effective than mood stabiliser monotherapy alone. In treatment of acute bipolar depression the current evidence is inadequate to support the use of lithium as monotherapy. The most effective treatment is combination of a mood stabiliser and an antidepressant which also minimises manic switches. FDA has approved olanzapine-fluoxetine combination and quetiapine monotherapy. Lamotrigine is also effective in the treatment of acute bipolar depression. For prophylaxis lithium, valproate and carbamazepine are effective while lamotrigine is primarily effective in preventing depressive episodes. Lithium is more effective in preventing manic than depressive episodes. Evidence for efficacy of antipsychotics in prophylaxis is limited