Expert Guidelines for
(reviewed Dec. 2010)
[Update 2010: The only guidelines which include a specific set of recommendations on Bipolar II, to my knowledge, are Canadian but they are getting pretty old (2005). They are not significantly different from what I've written about below ( I have just kept my descriptions from years ago when these recommendations were new...). To my knowledge there are no major new guidelines, with new and different recommendations, to point you toward at this point.]
There are three sets of U.S. guidelines for treatment of bipolar disorder, and more from abroad. They are very similar in their recommendations, although European versions generally place more emphasis on the use of lithium and are less cautious with the use of antidepressants. The three U.S. versions come from:
A. The American Psychiatric Association; it's guidelines are acknowledged as outdated
B. The Expert Consensus series: 2004, also too old, but linked below if you want them
C. The Texas Medical Algorithm Project -- TMAP, also now too old, but most recently revised of these three
These recommendations address all forms of bipolar disorder, and in general emphasize the following principles:
1. Rely on mood stabilizers.
2. Add a bipolar-specific psychotherapy if available.
3. Use antidepressants with caution
But if you'd like to see for yourself, which I'd encourage, here are some hints on how to read and how to access these documents. The most recently revised is the TMAP, in July 2005; shortly before that came the December 2004 update of the Expert Consensus series; and earlier, the 2002 APA guidelines. Details and links to each follow below, in that order. More information on the specific medications named is available on the Mood Stabilizers page of this website.
Texas Medical Algorithm Project (TMAP)
An algorithm is a series of suggested steps. The TMAP has three such series, one each for manic symptoms, depression symptoms, and mixed states. All are directed toward Bipolar I. There are no separate guidelines for Bipolar II in the TMAP. You'll find the algorithms, and a description for doctors of each step, on the TMAP website (see Algorithms and Manuals). The 2005 update has not reached their website as of this writing (July), so here is a summary of those changes.
Overall, their emphasis is on mood stabilizers and select use of newer "atypical antipsychotics". Antidepressants were "demoted" as a treatment of bipolar depression in 2005, although a "minority opinion" would have preferred to keep them ranked higher. The TMAP website specifically suggests tapering off antidepressants for patients with rapid cycling (Physician's Manual, page 11), as you'll see emphasized on this website.
Expert Consensus Guidelines Series
Updated in December 2004 [which is getting pretty old], the guide for patients and families, written in good plain English, is a valuable starting place for anyone.
There are specific recommendations for Bipolar II buried a little deeper in the document. The experts recommended:
- (#39, pg 85) For long term treatment ("maintenance strategies") of bipolar II, use lithium or lamotrigine or both together.
- As for bipolar depression, bipolar II was not addressed separately. In general, the experts rely heavily on lithium and lamotrigine; and use caution with antidepressants (presumably, say the editors, out of concern for the risk of inducing hypomania and mania; and in recognition of lack of data supporting antidepressants in this role, versus lithium alone).
- (#14, pg 61) For hypomania without a history of rapid cycling, use a "traditional mood stabilizer" (lithium, Depakote, carbamazepine).
The editors noted that the enthusiasm for lamotrigine, which is prominent in this 2004 update, was suprising given the single randomized trial of this agent available at the time of the surveyCalabrese (1999, Bipolar I only).
As I now derive a substantial income from the lamotrigine manufacturer, described in my essay on funding of this website, any additional comments here on lamotrigine would have to be interpreted with great caution. Instead I refer you to the guidelines themselves.
American Psychiatric Association Guidelines
This is a very large document. If you can read the whole thing, fine. Here are some specific sections I think offer special value:
Treatment Recommendations, "Executive
[take that link and scroll to page 9]
One of the reasons for offering you this connection is so that you may confirm that my website is very much within the "treatment guidelines" of the APA; exceptions are noted as such.
Role of Psychotherapy
(This section is now outdated. See my summary of the data on bipolar-specific psychotherapies).
What's really new?
You'd have to read the whole thing to be sure, and I've read or skimmed all of it. Overall, other than now being very comprehensive, a really nice complete summary of treating bipolar disorder, what's new compared to the last expert summary is:
My editorial comments, then: lamotrigine is very prominent in this document, a 2002 preview of what happened in the 2004 Expert Consensus Guidelines report above. By comparison, oxcarbazepine is also subject to the same "lack of experience and data" problem; indeed we have even less experience with it overall. But, it is a very close cousin to carbamazepine, with which we have extensive experience.
For a discussion of "how to choose", return to the page on Mood Stabilizer Options and read on.