The scientific literature contains numerous studies on the treatment of bipolar disorder, and there are now more than a dozen treatment guidelines. In German-speaking countries, the guidelines of the DGPPN are recommended. In the UK, the National Institute for Health and Clinical Excellence (NICE) has gained recognition, while in Canada, the Canadian Network for Mood and Anxiety Treatment (CANMAT) plays a significant role. Meanwhile, also the American Psychiatric Association (APA) has formulated “Practice Guidelines for the Treatment of Patients with Bipolar Disorder.”
As a result, experiences and treatment approaches for bipolar disorder vary widely and are not always uniform.
For treatment of Bipolar Disorder contact our leading psychiatrist, Dr. Kowal:
Read more about anxiety disorders:
- Bipolar Disorder, Diagnostic & Treatment
- What is Mania and Hypomania?
- Cyclothymic Disorder
- History of Treatment of Bipolar Disorder
- Mood Stabilizers in Treatment of Bipolar Disorder
- Treatment with Lithium of Bipolar Disorder
CHMC’s Use of CANMAT Treatment Guidelines
Bipolar disorder is a severe, recurring psychiatric illness that, when left untreated, can lead to significant social disadvantages, disability, and neurotrophic brain changes. Treatment goals include symptom remission during acute episodes, prevention of relapses, and neuroprotection.
Since 2018, new studies, meta-analyses, and revisions of treatment recommendations from the Canadian Network for Mood and Anxiety Treatments (CANMAT) have been published for the management of patients with Bipolar Disorder. These recommendations are based on scientific studies and international guidelines.
Despite the well-established effectiveness of pharmacological therapies, CANMAT guidelines recommend additional psychosocial treatment as an important therapy component. The psychosocial approaches include psychotherapy, individual and group psychoeducation, as well as the involvement of family members and, if necessary, supported employment.
CHMC uses the CANMAT guidelines, containing the most comprehensive data and treatment options with medication for bipolar disorder.
CANMAT Recommendations for Treatment with Medication
Medication treatment for bipolar disorder suppresses symptoms, prevents symptom recurrence, and has neuroprotective effects. Depending on the phase of Bipolar Disorder, treatment with medication can be categorized into acute therapy, continuation therapy, and relapse prevention.
Treatment with Medication for Acute Mania
Treatment for acute mania suggests monotherapy with lithium, valproate, or various atypical antipsychotics as the first-line options. Lithium continues to be the “gold standard” for treating bipolar disorders. It is the first-line option for acute mania and particularly for long-term treatment of bipolar disorders.
Combinations of a mood-stabilizing agent (lithium, valproate) with an atypical antipsychotic are also recommended due to their particularly pronounced efficacy.
As a general rule, medications that were effective during the acute phase are also suitable for maintenance therapy.
Treatment with Medication for Bipolar Depression
In bipolar depression, the best evidence supports monotherapy with quetiapine, followed by lithium and lurasidone. Combining a mood stabilizer or antimanic agent (e.g., lithium or atypical antipsychotics) with lamotrigine or an antidepressant, especially an SSRI or bupropion, is also recommended.
Treatment with Medication for Relapse Prevention
As the first-line options for relapse prevention are recommended: lithium, quetiapine, lamotrigine (primarily for preventing depressive episodes), aripiprazole (for preventing manic episodes), olanzapine, valproate, and asenapine. Also, the combinations of lithium and valproate and lithium or valproate with quetiapine can be used. Aripiprazole and risperidone are recommended in combination with a mood-stabilizing agent.
In relapse prevention, combinations of lithium or valproate with aripiprazole, risperidone, and lamotrigine are recommended. Lithium and valproate can also be combined with risperidone and aripiprazole as depot injections.
Treatment with Medication for Rapid Cycling
A course of bipolar disorder with four or more episodes within one year is called “rapid cycling.” Treatment for rapid cycling is challenging. Hypothyroidism, use of antidepressants, or substance abuse are often associated with this course pattern. Patients with rapid cycling seem to respond less well to antidepressants than other bipolar patients. The risk of depressive relapses is tripled in rapid cycling. The CANMAT guidelines recommend against the use of antidepressants in rapid cycling. Lithium and lamotrigine have shown antidepressant effects in controlled studies. For the long-term treatment of rapid cycling, the CANMAT guidelines recommend combination therapies with valproate and lithium.
Treatment with Atypical Antipsychotics
Atypical antipsychotics are also considered first-line options for mania, bipolar depression, and long-term treatment (especially quetiapine). Asenapine and paliperidone are newly recommended as monotherapy and in combination for the treatment of acute mania.
Treatment with Antiepileptic Medication
Anticonvulsants have differential efficacy for the manic and depressive poles. Valproate has an acute antimanic effect, while lamotrigine has a preventive effect against depression. Lamotrigine has been newly recommended for the acute treatment of bipolar depression.
CANMAT Treatment Guidelines for Bipolar Disorder. Summary
Epidemiological data shows that bipolar disorders typically persist lifelong and that the frequency of episodes may even increase over time. There is also increasing evidence that bipolar disorder may be a neuroprogressive disease. Each relapse can lead to neurotrophic and inflammation-related changes in the grey and white matter of the brain. Such changes will cause neurocognitive deficits affecting memory and concentration and decrease the emotional modulation. Therefore, all patients with bipolar disorder require long-term therapy and relapse prevention.
A variety of pharmacological substances are available for the treatment of bipolar disorder. There are now several approaches to choose from, some of which are equally effective in clinical practice. Treatment guidelines for bipolar disorder vary widely and are not always uniform. CHMC uses the CANMAT guidelines, containing the most comprehensive data and treatment options for bipolar disorder.
The choice of therapy depends on the individual’s medical history, previous treatment experiences, and the specific characteristics of their symptoms and illness progression. In addition to medication, psychoeducational and psychosocial interventions can be beneficial.
For treatment of Bipolar Disorder contact our specialists at CHMC: