Bipolar disorder is a chronic psychiatric condition characterized by fluctuations in mood, energy levels, and activity. The management of bipolar disorder requires a comprehensive approach that combines pharmacological interventions, psychosocial treatments, and regular monitoring. The Canadian Network for Mood and Anxiety Treatments (CANMAT) and the International Society for Bipolar Disorders (ISBD) collaborated to develop evidence-based guidelines to aid clinicians in the management of patients with bipolar disorder. This article discusses the key recommendations outlined in the CANMAT and ISBD 2018 guidelines, providing specific details to enhance understanding and implementation.
Diagnosis and Assessment: Accurate diagnosis is crucial for effective treatment. The guidelines stress the importance of conducting a comprehensive assessment, including a detailed history, evaluation of symptoms, and consideration of comorbidities. It is essential to differentiate bipolar disorder from other psychiatric conditions, such as major depressive disorder. Moreover, the guidelines highlight the significance of identifying the specific subtype of bipolar disorder (e.g., bipolar I, bipolar II) to guide treatment decisions.
The use of validated assessment tools is recommended. The Mood Disorder Questionnaire (MDQ) is a screening instrument that aids in identifying bipolar disorder and assessing its severity. The Young Mania Rating Scale (YMRS) is utilized to measure manic symptoms accurately. These tools assist in accurate diagnosis, monitoring treatment response, and assessing symptom severity over time.
Treatment Phases and Goals: The guidelines recognize three treatment phases in bipolar disorder: acute, maintenance, and long-term. In the acute phase, the primary objective is symptom stabilization and restoration of functioning. This phase often involves hospitalization, especially in severe cases. The guidelines emphasize the importance of a comprehensive treatment plan that addresses acute symptoms while considering potential side effects of medications.
The maintenance phase focuses on preventing relapse, reducing symptoms, and improving overall quality of life. During this phase, long-term pharmacotherapy is typically required. The guidelines suggest the use of mood stabilizers as the first-line treatment for maintenance, including lithium, valproate, and lamotrigine. These medications have shown efficacy in preventing relapses and reducing the severity of mood episodes.
In the long-term phase, the guidelines highlight the importance of a holistic approach to care. This includes addressing physical health, promoting healthy lifestyle habits, and supporting psychosocial functioning. Regular monitoring, ongoing medication management, and the involvement of the patient in shared decision-making are essential in this phase.
Pharmacological Interventions: Pharmacotherapy is a cornerstone of bipolar disorder treatment. The guidelines recommend mood stabilizers as the primary pharmacological intervention. Lithium, a well-established treatment, is recommended for both acute and maintenance phases. It has proven efficacy in reducing the risk of relapse and preventing suicide in individuals with bipolar disorder. Valproate, another first-line option, has demonstrated effectiveness in treating acute mania and preventing future episodes. Lamotrigine is recommended for maintenance treatment, particularly for bipolar II disorder. These medications offer a range of options to tailor treatment to individual patients.
Second-generation antipsychotics, such as quetiapine and olanzapine, are considered as alternative first-line options, particularly for patients with prominent manic symptoms. These medications can effectively control acute manic episodes and provide mood stabilization. The guidelines urge caution in the use of antidepressants due to the risk of mood destabilization and switch into mania. However, if used, the guidelines recommend combining antidepressants with a mood stabilizer to minimize these risks.
In addition to pharmacotherapy, psychosocial interventions play a vital role in the management of bipolar disorder. The guidelines emphasize the value of psychoeducation, cognitive-behavioral therapy (CBT), family-focused therapy, and interpersonal and social rhythm therapy (IPSRT).
Psychoeducation aims to enhance patient and family understanding of bipolar disorder, treatment options, and strategies for managing symptoms. CBT helps individuals develop coping skills, recognize and modify negative thought patterns, and enhance problem-solving abilities. Family-focused therapy involves educating family members about bipolar disorder and improving communication and problem-solving within the family unit. IPSRT focuses on stabilizing social and circadian rhythms, which can help prevent mood episodes. These psychosocial interventions are evidence-based and have been shown to improve medication adherence, reduce relapse rates, and enhance overall psychosocial functioning in individuals with bipolar disorder.
The guidelines address considerations for special populations, including children and adolescents, pregnant and postpartum women, and older adults with bipolar disorder. Specific challenges and potential risks associated with certain medications during pregnancy and lactation are carefully evaluated. For children and adolescents, early intervention and a multimodal approach that includes psychoeducation, psychosocial interventions, and carefully selected pharmacotherapy are recommended. For pregnant and postpartum women, the guidelines emphasize the importance of balancing the potential risks of medication exposure with the benefits of managing the disorder effectively. In older adults, the guidelines highlight the need for careful medication management, considering potential interactions and age-related physiological changes. Regular monitoring for potential adverse effects and adjusting treatment as necessary is crucial for this population.
Regular monitoring and follow-up are essential components of bipolar disorder management. The guidelines emphasize the importance of ongoing assessment of mood symptoms, treatment response, medication adherence, and potential side effects. Patients should actively participate in their treatment plans, and shared decision-making should be encouraged. Collaboration between healthcare providers, patients, and families is crucial to optimize outcomes. Regular check-ins, monitoring of symptoms, and adjusting treatment as needed are necessary to ensure effective management and prevent relapses.
The CANMAT and ISBD 2018 guidelines provide evidence-based recommendations for the management of patients with bipolar disorder. These guidelines emphasize accurate diagnosis, comprehensive assessment, and a multimodal approach involving pharmacological and psychosocial interventions. By following these guidelines, clinicians can enhance the quality of care for individuals with bipolar disorder, improve symptom management, prevent relapse, and promote overall well-being. Lakshmi et al., (2018) make a compelling argument the it is essential to implement these guidelines in clinical practice and consider individual patient factors to provide personalized and effective care for individuals living with bipolar disorder.
Title: Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) 2018 guidelines for the management of patients with bipolar disorder
Authors: Lakshmi N Yatham, Sidney H Kennedy.Sagar V Parikh, Ayal Schaffer,David J Bond, Benicio N Frey, Verinder Sharma, Benjamin I Goldstein, Soham Rej, Serge Beaulieu, Martin Alda, Glenda MacQueen, Roumen V Milev, Arun Ravindran, Claire O’Donovan, Diane McIntosh, Raymond W Lam, Gustavo Vazquez, Flavio Kapczinski, Roger S McIntyre, Jan Kozicky, Shigenobu Kanba, Beny Lafer, Trisha Suppes, Joseph R Calabrese, Eduard Vieta, Gin Malhi, Robert M Post, Michael Berk.
Journal: Bipolar Disorder
Publication Date: 2018 Mar
Volume: 20
Issue: 2
Page Range: 97–170
Publication Date: 2018 Mar 14
DOI: 10.1111/bdi.12609