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

Abstract

The Canadian Network for Mood and Anxiety Treatments (CANMAT) previously published treatment guidelines for bipolar disorder in 2005, along with international commentaries and subsequent updates in 2007, 2009, and 2013. The last two updates were published in collaboration with the International Society for Bipolar Disorders (ISBD). These 2018 CANMAT and ISBD Bipolar Treatment Guidelines represent the significant advances in the field since the last full edition was published in 2005, including updates to diagnosis and management as well as new research into pharmacological and psychological treatments. These advances have been translated into clear and easy to use recommendations for first, second, and third‐ line treatments, with consideration given to levels of evidence for efficacy, clinical support based on experience, and consensus ratings of safety, tolerability, and treatment‐emergent switch risk. New to these guidelines, hierarchical rankings were created for first and second‐ line treatments recommended for acute mania, acute depression, and maintenance treatment in bipolar I disorder. Created by considering the impact of each treatment across all phases of illness, this hierarchy will further assist clinicians in making evidence‐based treatment decisions. Lithium, quetiapine, divalproex, asenapine, aripiprazole, paliperidone, risperidone, and cariprazine alone or in combination are recommended as first‐line treatments for acute mania. First‐line options for bipolar I depression include quetiapine, lurasidone plus lithium or divalproex, lithium, lamotrigine, lurasidone, or adjunctive lamotrigine. While medications that have been shown to be effective for the acute phase should generally be continued for the maintenance phase in bipolar I disorder, there are some exceptions (such as with antidepressants); and available data suggest that lithium, quetiapine, divalproex, lamotrigine, asenapine, and aripiprazole monotherapy or combination treatments should be considered first‐line for those initiating or switching treatment during the maintenance phase. In addition to addressing issues in bipolar I disorder, these guidelines also provide an overview of, and recommendations for, clinical management of bipolar II disorder, as well as advice on specific populations, such as women at various stages of the reproductive cycle, children and adolescents, and older adults. There are also discussions on the impact of specific psychiatric and medical comorbidities such as substance use, anxiety, and metabolic disorders. Finally, an overview of issues related to safety and monitoring is provided. The CANMAT and ISBD groups hope that these guidelines become a valuable tool for practitioners across the globe.

Current understanding of bipolar disorder: Toward integration of biological basis and treatment strategies

“…On the other hand, treatment options for acute bipolar depression are relatively limited. There is evidence to support the efficacy of quetiapine and olanzapine, as well as combination of olanzapine and fluoxetine . Lithium and lamotrigine are also suggested to be effective.…”

“…Efficacy of electroconvulsive therapy may be mediated either by upregulation of BDNF or other growth factors or by reduced excitability associated with upregulation of Homer1a . Though repetitive transcranial magnetic stimulation is reported to be effective for unipolar depression and mania, its efficacy for bipolar depression has not yet been proven . Efficacy of transcranial direct current stimulation and subcallosal deep brain stimulation has not been proven by RCT for depression.…”

“…Carbamazepine is also suggested to be effective. Combination of lithium or valproic acid and atypical antipsychotics, such as quetiapine, aripiprazole, lurasidone, and ziprasidone, may also be effective . Benzodiazepine use should be minimized because it might worsen the course of BD, though data are limited …”

In the Realm of Psychoneuroimmunology: The Role of Celecoxib as an Add-On Treatment for Bipolar Mania

“…Furthermore, it also jeopardizes the patients’ quality of life both medically and psychologically [1-3]. Approximately half of all BPAD patients respond positively to the currently available treatments (mood stabilizers, antipsychotics), with alternative therapies only helping a small percentage of patients [1, 4-8]. …”

“…On the other hand, according to the Canadian Network for Mood and Anxiety Treatments and International Society for BPADs, celecoxib has not yet been appointed as an adjuvant treatment for BPAD patients, either in manic, mixed or depressive phases, despite promising findings from a number systematic reviews. Further studies are needed to create these guidelines [8]. Notably, in cases of unipolar depression, the British Association of Psychopharmacology recommends celecoxib as an alternative treatment in severe, resistant cases [45].…”