Decision tree for the treatment of bipolar disorder

Clinicians managing patients with bipolar disorder confront a myriad of complex treatment decisions. This complexity limits the practicality of treatment guidelines, which attempt to be comprehensive. A user-friendly guide can, however, be constructed by considering only the most common early critical decision points likely to be encountered in the management of bipolar patients: new onset of an acute manic or mixed episode, interepisode treatment entry, and initial treatment for acute bipolar depression. Three general treatment principles, i.e., use proven treatments first, use a mood stabilizer in every phase of the illness, and use a multiphase treatment strategy to link current assessment with an appropriate treatment plan, can be applied to guide decision making at critical decision points that follow entry into clinical care. To guide the selection of appropriate therapeutic agents, a simple grading system can be used to evaluate the weight of evidence supporting use of various options. Multiple high-quality studies with positive results support the use of lithium, divalproex, carbamazepine, olanzapine, and haloperidol as initial intervention for acute mania; other agents with positive results in one double-blind mania trial are reasonable first-line alternatives. In the absence of high-quality evidence to guide treatment selection for nonacutely ill bipolar patients, guidelines recommend maintenance mood-stabilizer treatment. Standard antidepressant medications do not appear to add statistically significant benefit beyond that of mood stabilizers alone; lithium and lamotrigine have shown some benefit, and promising preliminary data have been presented on the antidepressant benefit of divalproex and topiramate as well.