Beyond evidence‐based treatment of bipolar disorder: Rational pragmatic approaches to management

Abstract

The evidence for efficacy of many currently available treatments for bipolar disorder is based on studies of nonrefractory patients with bipolar disorder. Therefore, not surprisingly, most treatment recommendations and guidelines for the treatment of bipolar disorder and its many comorbidities depend heavily on data from placebo controlled randomized clinical trials (RCTs), but these RCTs provide little direction for the clinician as to what next steps might be optimal in non‐ or partial‐responders and in those with ongoing medical and psychiatric comorbidities. Given this and the paucity of RCTs at later treatment junctures, we thought it appropriate to begin a discussion of the quality of the data that some experts in the field might consider using in choosing and sequencing drugs and their combination. We acknowledge that many other clinical investigators may prefer very different sequences, but thought the suggestions offered here might be useful to some clinicians in the field, might start discussions of other options in the literature, and, at the same time, provide a preliminary outline for a new round of much‐needed clinical trials to better inform clinical practice. Given the very wide range of the quality of the data and clinical principles on which the current suggestions are based, only minimal references are included and a comprehensive review of the literature supporting each option would be outside the scope of this manuscript.

Bipolar disorder as a condition of heterogeneity: Embracing an adaptive psychosocial approach

“…This approach is encouraged by the overall strong evidence for psychosocial approaches, and cognitive‐behavioral therapy in particular, across disorders. Furthermore, this suggestion is the natural analogue to the multiple‐treatment target approach encouraged by Post and associates1 for pharmacotherapy, and respects the changing symptom profile inherent to bipolar disorder 3…”

“…The efficacy of combining psychotherapeutic, cognitive‐rehabilitation, and exercise‐based approaches is awaiting empirical validation in bipolar disorder. As such, like Post and associates’1 recommendations for novel and combined pharmacologic treatment, we are underscoring the importance of considering multiple methods and treatment targets on the psychosocial side of care ahead of full validation of these combination strategies.…”

“…Post et al1 provide a call for consideration of a polypharmacy approach to later‐stage and treatment‐refractory bipolar patients, discussing potential future directions in the pharmacological management of bipolar disorder that can be delivered alongside a program involving psychosocial and lifestyle approaches. In this commentary, we provide additional attention to the nature of psychosocial interventions that deserve attention in the later‐stage, comorbid, and complex bipolar patients that are poorly represented in clinical trials.…”

“…2). To address the more heterogeneous bipolar patients with psychiatric and medical comorbidities, which are abundant in bipolar disorder,1 efforts have been made to elucidate an “integrated” psychosocial approach that is designed to target symptoms of both the bipolar disorder and the comorbidity in the context of a single treatment. Such efforts have generally yielded mixed findings.…”

Changing the clinical landscape for treatment of bipolar disorder—To be (cautiously) welcomed

“…The review by Post et al 1 is important. The authors, with undoubted expertise in this field, describe measures addressing clinical issues in bipolar disorders (BD).…”