Page 6 - e-book CPG - Bipolar Disorder

CLINICAL PRACTICE GUIDELINES

K KEY RECOMMENDATIONS
E
O
R
D
E
N
O

N
M
Y
M
E
S
C
A
I
T
KEY RECOMMENDATIONS KEY RECOMMENDATIONS

he highlighted by the CPG Development Group (DG) as the
T The following recommendations are e f hi ol g l ow i g i ng r eco y m t he en P G t i on ev el r op hi g en i t g G hted p b y ( D t he ) C s P G he
en
hted
a

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l
m
C

da
m
m

ol
s
he
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m
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b
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on
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The following recommendations are highlighted by the CPG Development Group (DG) as the Development Group (DG) as the
s
t
T
ou
hl
ow
hl
r

t
ng

k
eythe main questions addressed in the CPG and should be
er
t
eco
at
an

q
r
h
r
da
eco
sw

en
P
an
t

ai
m
ad
key recommendations that answer the main questions addressed in the CPG and should be dressed in the CPG and should be
k key recommendations that answer t he m m ai m n en ue s t t i i on s s t h at dres sw er i n he t he m C n G q ue s d t i on ho ul d be
s
s
m
da
ad
i
t
on
s
on
ey
an
sed
prioritised for implementation.
prio r i t i sed f or i m pl emen t atio n.
prioritised for implementation. prioritised for implementation.

D DIAGNOSIS DIAGNOSIS
S
DIAGNOSIS
I
O
I
A
N
G
S
sho
ul
di
sorder
ar
d
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po
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sorder he Diagnostic and Statistical Manual of
i
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on

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ba

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e
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sed
  Bipolar disorder should be diagnosed based on t t sho D i ag b no di t ag an d S t atis sed on an e D l i of
 Bipolar disorder should be diagnosed based on the Diagnostic and Statistical Manual of agnostic and Statistical Manual of
ul
e
h
ar
i
ua
sed

t
no
h
B
B

po

cal
l
M
ag
Mxt Revision (DSM-5-TR) or International Classification
M Mental Disorders Fifth Edition, Te e en R al e v D i s i sorders M - f 5 t h - T E R di ) t i o on I nt T erna R t i on v al s i o C n l assi S f i M - 5 - T n
e
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on

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Mental Disorders Fifth Edition, Text Revision (DSM-5-TR) or International Classification R) or International Classification
o of Diseases Eleventh Revision (ICD- i11). .
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of Diseases Eleventh Revision (ICD-11). ses Eleventh Revision (ICD-11).
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D

T TREATMENT AND MONITORING
R
T
D
I

T
N
M
O
M
T
R
N
E
T
N
N
G
A

E
TREATMENT AND MONITORING EATMENT AND MONITORING
R
O
I
A
  Antipsychotics or mood st ab lisers, either r as mono t oo d r ap ab or i sers, bi ei na he t i r o n, sho o ul no d t he r
choas
d stabi
mtherapy or combination, should be
m
co
i
i
y
cs
st
t
l
he
ei

i
he
t
sy
ntip
A
A
l
i
sers,
o
ntip
or
or
no
m
cs
i
t
m
 Antipsychotics or mood stabilisers, either as monotherapy or combination, should be apy or combination, should be
oo
m
as
cho
be
t
sy

used to treat acute mania or depressive episodes t in bipolar disorder (BD). .
use

acu
t
d t
v
pressi
an
ar
de
acu

di
t

used to treat acute mania or depressive episodes in bipolar disorder (BD). e episodes in bipolar disorder (BD).
sod
o
an

e
po
t
m
use
i
n bi
e
)
es
l
m
a or
D

B
i
t
a or
e epi
o
pressi
t

i
r

de
ea
v
d t

sorde
ea
r
r
(
ep

m
ad
epshort-term adjunctive treatment
ntid

ernot as
m
-
as
r

no
 used as
t
m
use
ntid
r
j
a

 Antidepressants may be used as short-term adjunctive treatment but not as unctive treatment but not as
  Antidepressants may be
t
t
ay
r
sho
r
-
essa
t
nt
m
t
t
shobut
t

be
er
A
s

bu
ad
be
d

ct
un
j
s
m
t

i
r
e
s
t
d
essa
nt
as
v
ea
use
A
ay

en

monotherapy in acute bipolar depression. apy in acute bipolar depression.
othe.
m monotherapy in acute bipolar depression

de

y
bi
ap

si
m
e
ar
i
on
n acut
on
l
othe
pres
po
on
r
.
r
D
ers
pa

I
i
 In BD with pacifiers:  In BD with pacifiers:
n
w
  In BD with specifiers:
i
B
t

:
ci
h
f

cal stabilisers may be used as monotherapy or
o o atypical antipsychotics (AAPs) or mood d an ab psy ser s t m cs ( A be P use or as oo on st ot ab i l r i ser y s or m
oo
i
cho
l
i
cho
aty
m
i

psy
o atypical antipsychotics (AAPs) or mood stabilisers may be used as monotherapy or ay be used as monotherapy or
an

pi
i
pi

i
m
cs
he
(
d
t

m
cal
t

d
or
ap
A
aty
s)
A
t
P
A
st
s)
ay

i
o
combi na t i on t he r ap y i n m i x ed f ea combi
combination therapy in mixed features
t
u
combination therapy in mixed features nation therapy in mixed features
r
es
o o AAPs may be used in anxious distr r P s
A
di
Aess
i
x
st
ess
o AAPs may be used in anxious distress may be used in anxious distress
ou
m
A
ay
s

A
be
P

i
n an

s
use
d

o
o o combination of mood stabilisers with A A P t s on or o an m o oo d r s m t a oo d l i sers w l i ser A i A P t h s e or an f er r t he r
combiAPs or another mood stabiliser is the preferred
t
bi
bi
on
i
t
i
he
i

o combination of mood stabilisers with AAPs or another mood stabiliser is the preferred mood stabiliser is the preferred
m
f

ed
oo
i
pre
h
s
t
t
t
s
A
l
a
combi
i
s
na
o

o
f
sers
w
na
t
i
d

h
ab
o
cho
i
m
d cy

t
r

t
ea
o
pi
r
treatment of choice in rapid cycling eatment of choice in rapid cycling

t treatment of choice in rapid cycling
a

f
r
ng
en
ce in
t
cl
i
o o antidepressants should be avoided in mixed features d an be use oi d de d h i n cau i t x i ed i f n r ap i d
uland used with caution in rapid
de
av

oi
ea
t

m
de
s
ea
f
sho
m
pressan
on
ed
x
i
d
i
t
pressan
w
av
ures
t

t
sho
t
s
n
be
d
t
i

an

an
t
o antidepressants should be avoided in mixed features and used with caution in rapid ures and used with caution in rapid
de
i
i
ul
d
o
cy cl i ng cycling
cycling
cycling
  For maintenance pharmacotherapy y r of BD: :

f
ai
D

o
 For maintenance pharmacotherapy of BD: ntenance pharmacotherapy of BD:
B

m
ai
Fo
t
ntenan
Fo

r
ap
he
r
ph
m
ce
ar
aco

m

ue
e
e
l
i
um
l
ne
t
q
i
ne
hi
m
w
p
l
e
r
are
i
apmonotherapy while lithium
-
f
hi

f

t
an
ed
r
hi
r
ed
i
f
ap
i
o o lithium and quetiapine are the
o lithium and quetiapine are the preferred first-line monotherapy while lithium plus monotherapy while lithium plus

l
um
d
i
um
ne
e
r
r
-
l
hi
st
e
q
r
t
r
f
i
ue
st
i
t

he

us
i
ap
are
l
o
d

an
t
t
r
he
o preferred first-line
he
p
t

y
r
iplus
ne
i

on

t
pl
q quetiapine or aripiprazole are the q preferred first-line combination therapy
ap
a
s
e
on

f

i
ue
r
i
combi
r
he

t
na

e
f
r
ne
quetiapine or aripiprazole are the preferred first-line combination therapy ed first-line combination therapy
y

ap
i
r
or
or
r
i
er
t

t
pi
ne
t
i
ue
ol
i
ap
f
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ed
pi
l
he
praz
praz
pre
pre
e ar

ne
e ar
r
er
he
-
i
t
a
t
t
i

o o antidepressant monotherapy should be avoided
av
t
an
de
ul

r
sho

ap
o antidepressant monotherapy should be avoided monotherapy should be avoided
t

an
oi

t
on
m
pressan
y
i
de
othe
d be
d
pressan

t
i
de
o
g
o aripiprazole or risperidone long-acting injectables may be considered in patients who ay be considered in patients who
o o aripiprazole or risperidone long g - a ac r i t pi i n praz ol e t ab l es m ay do be e con si - de r t ed g i n i nj pa t t i en t l s w m
ec
e
praz
n

spe

i
i
or
n
r
i
or
ac
i
spe

l

r
ol
on
r
g
i
i
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ab
e
es
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nj
do
r
ho
a
o-acting injectables may be considered in patients who
ec
r
pi
i
on
have poor adherence to oral medications especially in preventi
ha v e poor ad he r en ce t o oral m ed i ca e poor esp he r a en l y ce n pr oral en mng manic episodes l
eci
i
v
i
on
t
sod
i
on
eci

i
ha
ev
i
t
ed
have poor adherence to oral medications especially in preventing manic episodes ly in preventing manic episodes
ng
ca

i
an
l
t
o
m
a
es
t
c

e
pi
s
s
ad
esp
  Serum lithium level should be monitored i t one week upon initiation or dose change and
l
i
t
t
hi
ev

i
o
erum
m
m
d

sho

up

atio
w
i
ni

t


i

um
i
t
 Serum lithium level should be monitored one week upon initiation or dose change and on initiation or dose change and
d
an
ored
l
do
e
S
r
be
ul
up
k
on
ored
be
on
w

ul
el
um
ev
on
ee
on
cha
e
l
n
l
S
ee
ng
el

hi
sho

e
erum
se
k
on
d

f
ev

ea
si
or
m
nd

i
i

x
hs

t
ery
si
i
m
n BD

every six months or earlier if indicated in BD. onths or earlier if indicated in BD.

ev
ery
r
i
x
every six months or earlier if indicated in BD. .
on
i
er
cated
l

  Electroconvulsive therapy sho uld be considered in both bipolar manic and depressive
d
E
sho


l
an
e
v
be
l
ul
ectr
nv
ar
ul
ul
bo
be
po
m
ul
d
de
ectr
ap
t
r
n
v

y
t
bo
i
ap
nv
r
de

he

ed

e
l
he
con
an
sho
E
d
oco
 Electroconvulsive therapy should be considered in both bipolar manic and depressive h bipolar manic and depressive
r
r
y
oco
con
i
e
bi
t
v
si
ed
si

c
i
si
pressi
t
si
h
n
de

t
ua
ep
es in
episodes in indicated situations.

si
i
t
i
i
on
nd
s.
cated
sod
episodes in indicated situations. episodes in indicated situations.

i
soci
i
a
r

ct
psy

cho
cho

sho
ad
un
e
r
ap
v
t
ed
i
he
as
es
ul
n
j

s
ap

en
i

d
cho
an

  Psychosocial interventions
t
r
be
 Psychosocial interventions and psychotherapies should be offered as an adjunctive d be offered as an adjunctive
al
nter
an
t
ul
v
en
cho
sho
sy
i
on
ntershould be offered as an adjunctive
i
v
 and psychotherapies

es
i
he
s
psy
i
o
t
d
soci
f
P

on
f
d
e
al
sy
P
t treatment for BD. . treatment for BD.
r

t
m
t
e
n
o
D

a
f
treatment for BD.
r
e
B

R RELAPSE PREVENTION AND ADHEREN CE
E
N
T
RELAPSE PREVENTION AND ADHERENCE EVENTION AND ADHERENCE
P
D
R

A
R
E
E
E
A

N
P
I
O

N
C
E
R
D
E
P
E
N
S
R
E
E
P
A
V
L
H
L
A
S

  Psychosocial interventions and psychotherapies shoul td be part of strategies in relapse
es
i
cho
n
ul
r
d
on
s
d
pa
an
r
t
sy
i
i
en
al
se

s
he

r
el
e
o
sho
psy
P
P
t

he
soci
cho
psy
f

t

t
soci
i
i
a
ap
sy
 Psychosocial interventions and psychotherapies should be part of strategies in relapse d be part of strategies in relapse

en
es
nter
es
r
cho
sho
g
nter
i
cho
d
v
v
an

on
s

ap

t

ul
ap

r
i
i
al
t
be
prev en t i on o f bi po l ar di s order .
prevention of bipolar disorder. prevention of bipolar disorder.
prevention of bipolar disorder.

SPECIAL POPULATION
 Shared decision-making in weighing the risks versus benefits of pharmacological

treatment should be done in pregnant and lactating women with bipolar disorder (BD).
o Atypical antipsychotics (AAPs) may be used in pregnancy.

o Valproate and carbamazepine should be avoided in pregnancy given their teratogenic
risks. Other mood stabilisers should be used with caution.

 For children and adolescents with BD:
o AAPs monotherapy may be used in manic or mixed episodes

o lurasidone and olanzapine/fluoxetine combination may be used in depressive
episodes
ii ii ii
 Patients with BD with co-morbid substance use disorder should be referred to psychiatric
ii
services.
vi

iii