MENTAL HEALTH

Health Evidence Bulletins - Wales
Team Leader: Dr Lyn Harris

Date of completion: 2.3.98

BIPOLAR DISORDER

This document is a supplement to, not a substitute for, professional skills and experience. Users are advised to consult the supporting evidence for a consideration of all the implications of a recommendation

The Statements The Evidence
5.1 Bipolar disorder: General
5.1a. Bipolar disorder should always be considered as a differential diagnosis in patients with depression i. i. American Psychiatric Association. Practice Guidelines. Washington DC: APA, 1996
(Type V evidence - expert opinion)
5.1b. Bipolar disorder may be complicated by substance misuse and this must be identified and treated if present i. i. American Psychiatric Association. Practice Guidelines. Washington DC: APA, 1996
(Type V evidence - expert opinion)
5.1c. Suicide rates are higher in people suffering from bipolar disorder and can be reduced with pharmacotherapy i,ii,iii. i. American Psychiatric Association. Practice Guidelines. Washington DC: APA, 1996
(Type I evidence - systematic review)
ii. Muller-Oerlinghausen B, Muser-Causemann B, Volk J. Suicides and parasuicides in high risk patient groups on and off lithium long-term medication. Journal of Affective Disorders 1992; 25: 261-269
(Type III evidence - non-randomised interventional studies)
iii. Coppen A, Standish-Barry H, Bailey J, Houston G, Silcocks P, Hermon C. Does Lithium reduce the mortality of recurrent mood disorders? Journal of Affective Disorders 1991; 23: 1-7
(Type III evidence - non-randomised interventional studies)
5.1d. Evidence from epidemiological and twin studies strongly suggests that bipolar disorder is a heritable illness. Bipolar patients considering having children may benefit from genetic counselling i,ii. i. Gershon ES. Genetics of Affective Illness, in Psychopharmacology: The Third Generation of Progress. Edited by Meltzer HL. New York: Raven Press, 1987
(Type V evidence -expert opinion);
ii. Nuremberger JI, Gershon E. Genetics, in Handbook of Affective Disorders, 2nd Edition. Paykel ES (ed.). New York: Churchill Livingstone, 1992
(Type III evidence -well designed interventional studies without randomisation)
5.1e. Non-compliance with mood stabilising medication is a major cause of relapse i. i. Jamieson KR, Akiskal HS. Medication compliance in patients with bipolar disorder. Psychiatric Clinics of North America 1983; 6: 175-192
(Type III evidence -well designed interventional studies without randomisation)
5.1f. In general, the least restrictive setting that is likely to allow for safe and effective treatment should be chosen. Factors guiding the choice of treatment setting include:
  • The patient’s ability to co-operate with treatment
  • The patient’s risk for suicidal or homicidal behaviour
  • The availability of psychosocial supports
  • Other clinical factors that make outpatient treatment unsafe or unlikely to be effectivei
i. American Psychiatric Association. Practice Guidelines. Washington DC: APA, 1996
(Type V evidence - expert opinion)

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5.2 Pharmacotherapy
5.2.1 Pharmacotherapy: Mood stabilisers
5.2.1a. The three mood stabilising drugs, lithium, sodium valproate and carbamazepine all have serious side-effects which must be considered when initiating or changing treatment. Serum level and side-effects should be monitored regularly i. i. American Psychiatric Association. Practice Guidelines. Washington DC: APA, 1996
(Type I evidence - systematic review)
5.2.2 Pharmacotherapy: Acute mania
5.2.2a. Lithium and sodium valproate are effective treatments in acute mania but can take 2-3 weeks to take effect i. i. Bowden CL. Efficacy of divaloproex vs lithium and placebo in the treatment of mania. The Depakote Mania Study Group. Journal of the Americal Medical Association 1994; 271:918-92
(Type II evidence - randomised controlled trial)
5.2.3. Pharmacotherapy: Acute Depression
5.2.3a. Lithium has an antidepressant effect in the acute depression of bipolar disorder but it can take 6 to 8 weeks to elicit this response.
There is no good evidence for the effectiveness of sodium valproate or carbamazepinei.
i. Zornberg GL, Pope HG. Treatment of depression in Bipolar Disorder: new directions for research. Journal of Clinical Psychopharmacology 1993; 13: 397-408
(Type I evidence - systematic review)
5.2.4. Pharmacotherapy: Maintenance Therapy
5.2.4a. Lithium is effective in reducing the frequency, duration and severity of manic and depressive episodes. It also decreases the intensity of episodes and reduces subsyndromal mood variations between episodes. Abrupt withdrawal can lead to relapse i. i. Goodwin FK, Jamison KR. Manic depressive illness. New York: Oxford University Press, 1990
(Type V evidence -expert opinion)
5.2.5. Pharmacotherapy: Neuroleptics
5.2.5a. Neuroleptics are superior to placebo in the treatment of acute mania i. i. Goodwin FK, Jamieson KR. Manic depressive illness. New York: Oxford University Press, 1990
(Type V evidence - expert opinion)

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5.2.5b. Neuroleptics are not as good as lithium for the specific normalisation of mood, but they act quicker i. i. Prien F, Point P, Caffey M et al. Comparison of lithium carbonate and chlorpromazine in the treatment of mania. Report of the Veterans Administration and National Institute of Mental Health Collaborative Study Group. Archives of General Psychiatry 1972; 26: 146-15
(Type II evidence - randomised controlled trial)
5.2.6 Pharmacotherapy: Antidepressants.
5.2.6a. Antidepressants are useful in lengthy bouts of depression but their use has not been well studied. When used, the lowest effective dose for the shortest period is advisable i. i. American Psychiatric Association. Practice Guidelines. Washington DC: APA, 1996
(Type V evidence - expert opinion)
5.3 Electroconvulsive Therapy (ECT)
5.3.1 ECT: Acute Mania
5.3.1a. Many patients experience a rapid response to ECT. The recommended treatment rate is 3 per week. There is no evidence for more frequent, or for prolonged treatment i,ii. i. American Psychiatric Association. Practice Guidelines. Washington DC: APA, 1996
(Type I evidence - systematic review)
ii. Mukherjee S, Sackeim HA, Schur DB. ECT of acute manic episodes: a review of 50 years experience. American Journal of Psychiatry 1994; 151(2): 169-176
(Type III evidence - systematic review)
5.3.2 ECT: Acute depression
5.3.2a. ECT should be considered as a primary treatment in bipolar depression whenever a rapid response is necessary or when pharmacological interventions are contraindicated e.g. in pregnancy i. There is a danger of inducing a manic episode with both ECT and antidepressants i. i. American Psychiatric Association. Practice Guidelines. Washington DC: APA, 1996
(Type V evidence - expert opinion)
5.4 Psychotherapy
5.4a. It is difficult to assess the adjunctive impact of psychosocial to pharmacological interventions in people with bipolar disorder.
The current research base is small and existing trials are flawed.
Published outcomes from substantive trials are needed before firmer conclusions can be drawn i.
i. Roth AD, Fonagy P. What works for whom? A critical review of psychotherapy Research. New York: Guilford Press, 1996
(Type I evidence - systematic review)

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Health Evidence Bulletins: Wales, Duthie Library, UWCM, Cardiff CF14 4XN. e-mail: weightmanal@cardiff.ac.uk