Page 20 - e-book CPG - Bipolar Disorder

CLINICAL PRACTICE GUIDELINES MANAGEMENT OF BIPOLAR DISORDER (2ND ED.)

4. TREATMENT

4. TREATMENT

TREATMENT
4.
There are several treatment options in BD, including pharmacological interventions,
TREATMENT
4.

psychotherapies and physical therapies. Ideally, treatment needs to be individualised and
There are several treatment options in BD, including pharmacological interventions,

TREATMENT
4.
There are several treatment options in BD, including pharmacological interventions,
patient-centered, focusing on patient-related outcomes.
psychotherapies and physical therapies. Ideally, treatment needs to be individualised and
TREATMENT
4.
There are several
4.
TREATMENT treatment options in BD, including pharmacological interventions,
psychotherapies and physical therapies. Ideally, treatment needs to be individualised and
patient-centered, focusing on patient-related outcomes.

psychotherapies and physical therapies. Ideally, treatment needs to be individualised and
There are several treatment options in BD, including pharmacological interventions,
patient-centered, focusing on patient-related outcomes.
4.1. Pharmacotherapy
patient-centered, focusing on patient-related outcomes.
psychotherapies and physical therapies. Ideally, treatment needs to be individualised and
There are several treatment options in BD, including pharmacological interventions,
There are several treatment options in BD, including pharmacological interventions,

Pharmacological treatment is one of the main pillars in the management of BD. There is ample
4.1. Pharmacotherapy
psychotherapies and physical therapies. Ideally, treatment needs to be individualised and
patient-centered, focusing on patient-related outcomes.
psychotherapies and physical therapies. Ideally, treatment needs to be individualised and
4.1. Pharmacotherapy
evidence on the effectiveness of treatment in acute mood episodes and the prevention of
Pharmacological treatment is one of the main pillars in the management of BD. There is ample
4.1. Pharmacotherapy
patient-centered, focusing on patient-related outcomes.
patient-centered, focusing on patient-related outcomes.
Pharmacological treatment is one of the main pillars in the management of BD. There is ample
relapses in the maintenance phase.
evidence on the effectiveness of treatment in acute mood episodes and the prevention of

Pharmacological treatment is one of the main pillars in the management of BD. There is ample
4.1. Pharmacotherapy
evidence on the effectiveness of treatment in acute mood episodes and the prevention of
relapses in the maintenance phase.
4.1. Pharmacotherapy
evidence on the effectiveness of treatment in acute mood episodes and the prevention of
Pharmacological treatment is one of the main pillars in the management of BD. There is ample
4.1. Pharmacotherapy
relapses in the maintenance phase.
Medications with mood-stabilising properties include lithium, antiepileptic agents (e.g.
Pharmacological treatment is one of
relapses in the maintenance phase. the main pillars in the management of BD. There is ample
evidence on the effectiveness of treatment in acute mood episodes and the prevention of
Pharmacological treatment is one of the main pillars in the management of BD. There is ample

valproate, carbamazepine, lamotrigine), haloperidol and AAPs. Choice of medications is
Medications with mood-stabilising properties include lithium, antiepileptic agents (e.g.
relapses in the maintenance phase. treatment in acute mood episodes and the prevention of
evidence on the effectiveness of
evidence on the effectiveness of treatment in acute mood episodes and the prevention of
Medications with mood-stabilising properties include lithium, antiepileptic agents (e.g.
based on the effectiveness, safety, availability and affordability of the medication, concomitant
valproate, carbamazepine, lamotrigine), haloperidol and AAPs. Choice of medications is
relapses in the maintenance phase.
Medications with mood-stabilising
relapses in the maintenance phase. properties include lithium, antiepileptic agents (e.g.
valproate, carbamazepine, lamotrigine), haloperidol and AAPs. Choice of medications is
medications, response to previous medication, family history of medication response, patient
based on the effectiveness, safety, availability and affordability of the medication, concomitant
Medications with mood-stabilising properties include lithium, antiepileptic agents (e.g.
valproate, carbamazepine, lamotrigine), haloperidol and AAPs. Choice of medications is

based on the effectiveness, safety, availability and affordability of the medication, concomitant
preference as well as medical and psychiatric co-morbidities. Refer to Appendix 5 on
medications, response to previous medication, family history of medication response, patient
based on the effectiveness, safety, availability and affordability of the medication, concomitant
valproate, carbamazepine, lamotrigine), haloperidol and AAPs. Choice of medications is
Medications with mood-stabilising properties include lithium, antiepileptic agents (e.g.
Medications with mood-stabilising properties include lithium, antiepileptic agents (e.g.
medications, response to previous medication, family history of medication response, patient
Recommended Adult Medication Dosages and Adverse Effects For Bipolar Disorder.
preference as well as medical and psychiatric co-morbidities. Refer to Appendix 5 on
valproate, carbamazepine, lamotrigine), haloperidol and AAPs. Choice of medications is is
medications, response to previous medication, family history of medication response, patient
based on the effectiveness, safety, availability and affordability of the medication, concomitant
valproate, carbamazepine, lamotrigine), haloperidol and AAPs. Choice of medications
preference as well as medical and psychiatric co-morbidities. Refer to Appendix 5 on
Recommended Adult Medication Dosages and Adverse Effects For Bipolar Disorder.
preference as well as medical and psychiatric co-morbidities. Refer to Appendix 5 on
medications, response to previous medication, family history of medication response, patient
based on the effectiveness, safety, availability and affordability of the medication, concomitant
based on the effectiveness, safety, availability and affordability of the medication, concomitant
Recommended Adult Medication Dosages and Adverse Effects For Bipolar Disorder.

Recommended Adult Medication Dosages and Adverse Effects For Bipolar Disorder.
medications, response to previous medication, family history of medication response, pati
preference as well as medical and psychiatric co-morbidities. Refer to Appendix 5 ent
 Response to treatment is defined as a ≥50% reduction of total score in standardised on
medications, response to previous medication, family history of medication response, patient

rating scales. dult Medication Dosages and Adverse Effects For Bipolar Disorder.
Recommended A
 Response to treatment is defined as a ≥50% reduction of total score in standardised on
preference as well as medical and psychiatric co-morbidities. Refer to Appendix 5
preference as well as medical and psychiatric co-morbidities. Refer to Appendix 5 on
 Response
 Remission to treatment is defined as a ≥50% reduction of total score in standardised
Recommended Adult Medication Dosages and Adverse Effects For Bipolar Disorder.
Recommended Adult Medication Dosages and Adverse Effects For Bipolar Disorder. in
rating scales. is an outcome of effectiveness measured by varying cut-off points
 Response to treatment is defined as a ≥50% reduction of total score in standardised
rating scales.
 Remission is an outcome of effectiveness measured by varying cut-off points in
standardised scales used in clinical trials.
rating scales.
 Response to treatment is defined as a ≥50% reduction of total score in standardised
 Remission is an outcome of effectiveness measured by varying cut-off points in
standardised scales used in clinical trials.
rating scales. treatment is defined as a ≥50% reduction of total score in standardised
 Response to
 Remission is an outcome of effectiveness measured by varying cut-off points in
 Response to treatment is defined as a ≥50% reduction of total score in standardised
standardised scales used in clinical trials.
standardised scales used in clinical trials.
rating scales.
4.1.1. Manic episode
rating scales. is an outcome of effectiveness measured by varying cut-off points in
 Remission
The manic episode an outcome of effectiveness measured by varying cut-off points in
standardised scales used in clinical trials.
 Remission is
4.1.1. Manic episode in BD poses its challenges with patients potentially having agitation,
 Remission is an outcome of effectiveness measured by varying cut-off points in

4.1.1. Manic episode
impulsivity, risky behaviour, aggression and reduced insight. The goal of treatment is to rapidly
standardised scales used in clinical trials.
standardised scales used in clinical trials.
The manic episode in BD poses its challenges with patients potentially having agitation,
4.1.1. Manic episode
The manic episode in BD poses its challenges with patients potentially having agitation,
achieve early remission and return to baseline levels of psychosocial functioning.
impulsivity, risky behaviour, aggression and reduced insight. The goal of treatment is to rapidly

4.1.1. Manic episode in BD poses its challenges with patients potentially having agitation,
The manic episode
impulsivity, risky behaviour, aggression and reduced insight. The goal of treatment is to rapidly
Pharmacotherapy remains one of the main treatments for a manic episode.
achieve early remission and return to baseline levels of psychosocial functioning.
impulsivity, risky beh
The manic episode aviour, aggression and reduced insight. The goal of treatment is to rapidly
4.1.1. Manic episode
4.1.1. Manic episode in BD poses its challenges with patients potentially having agitation,
achieve early remission and return to baseline levels of psychosocial functioning.
Pharmacotherapy remains one of the main treatments for a manic episode.
The manic episode in BD poses its challenges with patients potentially
27, level I having agitation,
achieve early remission and return to baseline levels of psychosocial functioning.
impulsivity, risky behaviour, aggression and reduced insight. The goal of treatment is to rapidly
The manic episode in BD poses its challenges with patients potentially having agitation,
Pharmacotherapy remains one of the main treatments for a manic episode.
In a large network meta-analysis on adults with acute bipolar mania:

impulsivity, risky behaviour, aggression and reduced insight. The goal of treatment is to rapidly
achieve early remission and return to baseline levels of psychosocial functioning.
Pharmacotherapy remains one of the main treatments for a manic episode.
impulsivity, risky behaviour, aggression and reduced insight. The goal of treatment is to rapidly

 most of the anti-manic agents (aripiprazole, asenapine, carbamazepine, cariprazine,
In a large network meta-analysis on adults with acute bipolar mania:

27, level I
achieve early remission and return to baseline levels of psychosocial functioning.
Pharmacotherapy remains one of the main treatments for a manic episode.
achieve early remission and return to baseline levels of psychosocial functioning.
In a large network meta-analysis on adults with acute bipolar mania:

27, level I
haloperidol, lithium, olanzapine, paliperidone, quetiapine, risperidone, valproate and
 most of the anti-manic agents (aripiprazole, asenapine, carbamazepine, cariprazine,
In a large network meta-analysis on adults with acute bipolar mania:
Pharmacotherapy remains one of the main treatments for a manic episode.
Pharmacotherapy remains one of the main treatments for a manic episode.
27, level I
 most of the anti-manic agents (aripiprazole, asenapine, carbamazepine, cariprazine,
ziprasidone) were more effective than placebo; lamotrigine was among those agents
haloperidol, lithium, olanzapine, paliperidone, quetiapine, risperidone, valproate and
 most of the anti-manic agents (aripiprazole, asenapine, carbamazepine, cariprazine,
In a large network meta-analysis on adults with acute bipolar mania: 27, level I
haloperidol, lithium, olanzapine, paliperidone, quetiapine, risperidone, valproate and
found not to be effective
ziprasidone) were more effective than placebo; lamotrigine was among those agents
haloperidol, lithium, olanzapine, paliperidone, quetiapine, risperidone, valproate and
27, level I
 most of the anti-manic agents (aripiprazole, asenapine, carbamazepine, cariprazine,
In a large network meta-analysis on adults with acute bipolar mania: 27, level I
ziprasidone) were more effective than placebo; lamotrigine
In a large network meta-analysis on adults with acute bipolar mania: was among those agents
 only aripiprazole, olanzapine, quetiapine, risperidone and valproate showed more
found not to be effective
 most of the anti-manic agents (aripiprazole, asenapine, carbamazepine, cariprazine,
ziprasidone) were more effective than placebo; lamotrigine was among those agents
haloperidol, lithium, olanzapine, paliperidone, quetiapine, risperidone, valproate and
 most of the anti-manic agents (aripiprazole, asenapine, carbamazepine, cariprazine,
found not to be effective
acceptability (all-cause discontinuation) compared with placebo
 only aripiprazole, olanzapine, quetiapine, risperidone and valproate showed more
haloperidol, lithium, olanzapine, paliperidone, quetiapine, risperidone, valproate and
found not to be effective
ziprasidone) were more effective than placebo; lamotrigine was among those agents
haloperidol, lithium, olanzapine, paliperidone, quetiapine, risperidone, valproate and
However, there was no mention on quality assessment of the primary papers. showed more
 only aripiprazole, olanzapine, quetiapine, risperidone and valproate
acceptability (all-cause discontinuation) compared with placebo
found not to be effective effective than placebo; lamotrigine was among those agents
 only aripiprazole, olanzapine, quetiapine, risperidone and valproate showed more
ziprasidone) were more
ziprasidone) were more effective than placebo; lamotrigine was among those agents
acceptability (all-cause discontinuation) compared with placebo
However, there was no mention on quality assessment of the primary papers.
acceptability (all-cause discontinuation) compared with placebo
 only aripiprazole, olanzapine, quetiapine, risperidone and valproate showed more
found not to be effective
found not to be effective
However, there was no mention on quality assessment of the primary papers.
The above findings were supported by a more recent network meta-analysis on adults with
acceptability (all-cause discontinuation) compared with placebo
 only aripiprazole, olanzapine, quetiapine, risperidone and valproate
 only aripiprazole, olanzapine, quetiapine, risperidone and valproate showed more
However, there was no mention on quality assessment of the primary papers. showed more
acute bipolar mania which showed:

28, level I
The above findings were supported by a more recent network meta-analysis on adults with
acceptability (all-cause discontinuation) compared with placebo

However, there was no mention on quality assessment of the primary papers.
acceptability (all-cause discontinuation) compared with placebo
The above findings were supported by a more recent network meta-analysis on adults with
 the following pharmacological agents as monotherapy were more effective than placebo
28, level I

acute bipolar mania which showed:
The above findings were supported by a more recent network meta-analysis on adults with
However, there was no mention on quality assessment of the primary papers.
However, there was no mention on quality assessment of the primary papers.
acute bipolar mania which showed:
in response to treatment -
 the following pharmacological agents as monotherapy were more effective than placebo
28, level I
The above findings were supported by a more recent network meta-analysis on adults with

acute bipolar mania which showed: 28, level I
 the following pharmacological agents as monotherapy were more effective than placebo
o antipsychotics (APs) - haloperidol, risperidone, paliperidone, olanzapine, quetiapine,
in response to treatment -
acute bipolar mania which showed: agents as monotherapy were more effective than placebo
 the following pharmacological
28, level I
The above findings were supported by a
more recent network meta-analysis on adults with
The above findings were supported by a more recent network meta-analysis on adults with
in response to treatment -
aripiprazole, cariprazine, ziprasidone
o antipsychotics (APs) - haloperidol, risperidone, paliperidone, olanzapine, quetiapine,
142, level I
 the following pharmacological agents as monotherapy were more effective than placebo
acute bipolar mania which showed: 28, level I
in response to treatment -

acute bipolar mania which showed:
o antipsychotics (APs) - haloperidol, risperidone, paliperidone, olanzapine, quetiapine,
o mood stabilisers - lithium, valproate, carbamazepine
aripiprazole, cariprazine, ziprasidone
 the following pharmacological agents as monotherapy were more effective than placebo
in response to treatment -
o antipsychotics (APs) - haloperidol, risperidone, paliperidone, olanzapine, quetiapine,
 the following pharmacological agents as monotherapy were more effective than placebo
aripiprazole, cariprazine, ziprasidone
 aripiprazole, olanzapine, quetiapine and risperidone had better acceptability (all-cause
o mood stabilisers - lithium, valproate, carbamazepine
in terms of response to treatment -
aripiprazole, cariprazine, ziprasidone
o antipsychotics (APs) - haloperidol, risperidone, paliperidone, olanzapine, quetiapine,
in response to treatment -
o mood stabilisers - lithium, valproate, carbamazepine
discontinuation) than placebo
 aripiprazole, olanzapine, quetiapine and risperidone had better acceptability (all-cause
aripiprazole, cariprazine, ziprasidone
o mood stabilisers - lithium, valproate, carbamazepine ridone, olanzapine, quetiapine,
o antipsychotics (APs) - haloperidol, risperidone, palipe
o antipsychotics (APs) - haloperidol, risperidone, paliperidone, olanzapine, quetiapine,
 aripiprazole, olanzapine, quetiapine and risperidone had better acceptability (all-cause
The quality of most of the primary papers were moderate based on the risk of bias assessment.
discontinuation) than placebo
 aripiprazole, olanzapine, quetiapine and risperidone had better acceptability (all-cause
o mood stabilisers - lithium, valproate, carbamazepine
aripiprazole, cariprazine, ziprasidone
aripiprazole, cariprazine, ziprasidone
discontinuation) than placebo
The quality of most of the primary papers were moderate based on the risk of bias assessment.
discontinuation) than placebo
 aripiprazole, olanzapine, quetiapine and risperidone had better acceptability (all-cause
o mood stabilisers - lithium, valproate, carbamazepine
o mood stabilisers - lithium, valproate, carbamazepine
The quality of most of the primary papers were moderate based on the risk of bias assessment.
In a systematic review of recently published RCTs after 2017 on adults with BD, results on
 aripiprazole, olanzapine, quet
discontinuation) than placebo iapine and risperidone had better acceptability (all-cause
The quality of most of the primary papers were moderate based on the risk of bias assessment.
 aripiprazole, olanzapine, quetiapine and risperidone had better acceptability (all-cause

29, level I

acute mania/hypomania found that:
In a systematic review of recently published RCTs after 2017 on adults with BD, results on

discontinuation) than placebo
The quality of most of the primary papers were moderate based on the risk of bias assessment.
In a systematic review of recently published RCTs after 2017 on adults with BD, results on
acute mania/hypomania found that:
discontinuation) than placebo 29, level I
In a systematic review of recently published RCTs after 2017 on adults with BD, results on
The quality of most of the primary papers were moderate based on the risk of bias assessment.
The quality of most of the primary papers were moderate based on the risk of bias assessment.
acute mania/hypomania found that:
29, level I
acute mania/hypomania found that: 29, level I

In a systematic review of recently published RCTs after 2017 on adults with BD, results on
In a systematic review of recently 29, level I
acute mania/hypomania found that:published RCTs after 2017 on adults with BD, results on
In a systematic review of recently published RCTs after 2017 on adults with BD, results on
29, level I
acute mania/hypomania found that: 29, level I 6
acute mania/hypomania found that:
6
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6

6
6 6