REVIEW – March 2009

The diagnostics and management of the bipolar disorder


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In recent years the number of treatment options available for the treatment of bipolar disorder has significantly increased. Data have been published about the effectiveness of atypical antipsychotics and mood stabilizers which have an impact on current treatment options. The Estonian Psychiatric Association approved the guidelines for treatment of the bipolar disorder compiled by the Canadian Network for Mood and Anxiety Treatments (CANMAT) in 2005 and in 2007 (updated version). The current review is based on these guidelines with the authors’ kind permission to use them. We present new data about effectiveness, safety, and tolerability in order to develop clinical recommendations for treatment of various phases of the bipolar disorder. The cornerstone of management of the disorder is pharmacotherapy. However, pharmacotherapy is effective only in case adjunctive psychosocial treatment is provided by a multidisciplinary team. Lithium, valproate and several atypical  antipsychotics are first-line drugs for acute mania. Bipolar depression and mixed states are frequently associated with suicidal acts; therefore, assessment of suicidal behaviour should always be an integral part of managing any bipolar patient. For management of the bipolar depression, recent data support quetiapine monotherapy as a first-line option. Lithium and lamotrigine monotherapy, olanzapine plus selective serotonin reuptake inhibitors (SSRI), and lithium or divalproex plus SSRI/bupropion are other first-line options. First-line options in maintenance treatment of the bipolar disorder are lithium, lamotrigine, valproate and olanzapine. Recent evidence supports a combination of olanzapine and fluoxetine as second-line maintenance therapy for bipolar depression. According to new data, also quetiapine monotherapy is recommended as a second-line option for management of acute bipolar II depression. Historical and symptom profiles help select treatment options.