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Updated Bipolar Disorder guidelines outline new drug therapy regimens. (First Changes Since 1994).

After more than 2 years of work, a detailed examination of the literature, and review by about 800 psychiatrists, the American Psychiatric Association has issued the first new guidelines for the treatment of bipolar disorder since 1994.

The most significant changes in the guidelines call for combination pharmacotherapy for the acute treatment of mania and the addition of lamotrigine as an option in the acute treatment of bipolar depression (Am. J. Psychiatry 159[suppl. 4]:1-50, 2002).

"The 1994 guidelines were hopelessly out of date," said Dr. Robert M.A. Hirschfeld, chair of the APA's Work Group on Bipolar Disorder, in an interview "There have been a number of new medications developed, mainly for mania but also for bipolar depression, in the intervening near decade, and they have made substantial improvements in our ability to treat bipolar disorder."

"I would hope that the guidelines help to improve treatment across the board," added Dr. Hirschfeld, chair of the department of psychiatry and behavioral sciences at the University of Texas, Galveston, "including the treatment of bipolar patients by primary care physicians."

In the acute treatment of severe mania, the new guidelines call for either lithium or valproate plus an atypical antipsychotic such as olanzapine or risperidone. Less severe mania may be treated by monotherapy with lithium, valproate, or an antipsychotic. When psychosocial therapy is used, it should be combined with pharmacorherapy.

In the acute treatment of bipolar depression, the new guidelines call for the initiation of either lithium or lamotrigine, but not antidepressant monotherapy. In more severe cases, the guidelines suggest that simultaneous treatment with lithium and an antidepressant may be an option. Electroconvulsive therapy may represent a reasonable alternative in patients with life threatening inanition, suicidality, or psychosis. The guidelines state that there is evidence that interpersonal or cognitive-behavioral therapy can be beneficial when added to pharmacotherapy.

Calling the new guidelines "an excellent facelift," Dr. Joseph Goldberg, director of the bipolar disorders research program at Cornell University, New York, said that they will provide an "informed means for substantiating how to choose among different agents for subtypes of illness like mixed states or rapid cycling. ... When I speak to practitioners around the country, many are very unfamiliar with the notion that different drugs may have specific kinds of mood-stabilizing properties, as opposed to broad mood-stabilizing properties."

For example, in patients who cycle rapidly (defined as four or more episodes within a year), the new guidelines say that physicians should treat any medical conditions, such as hyperthyroidism, that could be contributing to the condition; they should taper antidepressants; and they should prescribe lithium, valproate, or lamotrigine as monotherapy or in combination.

Following remission of an acute episode, the guidelines recommend maintenance therapy with lithium or valproate. Possible alternatives include lamotrigine, carbamazepine, or oxcarbazepine. Antipsychotics should be discontinued unless they are needed for the control of ongoing psychosis or perhaps prophylaxis against recurrence.
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Author:Finn, Robert
Publication:Clinical Psychiatry News
Article Type:Brief Article
Geographic Code:1USA
Date:Jun 1, 2002
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