Practice Guideline for the Treatment of Patients With Bipolar Disorder (Revision)

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INTRODUCTION

This practice guideline summarizes data on the specific somatic and psychosocial interventions that have been studied in the treatment of bipolar disorder. It begins at the point at which a diagnostic evaluation performed by a psychiatrist has raised the concern that an adult patient may be suffering from bipolar disorder. According to the criteria defined in DSM-IV-TR (1), patients with bipolar I disorder have experienced at least one episode of mania; they may have experienced mixed, hypomanic, and depressive episodes as well. Patients with bipolar II disorder have experienced hypomanic and depressive episodes. Cyclothymic disorder may be diagnosed in those patients who have never experienced a manic, mixed, or major depressive episode but who have experienced numerous periods of depressive symptoms and numerous periods of hypomanic symptoms for at least 2 years (or 1 year for children [1]), with no symptom-free period greater than 2 months. Finally, patients with depressive symptoms and periods of mood elevation who do not meet criteria for any specific bipolar disorder may be diagnosed with bipolar disorder not other-wise specified. For patients with depressive symptoms and no history of mania or hypomania, the psychiatrist should refer to the APA Practice Guideline for the Treatment of Patients With Major Depressive Disorder (2).

In addition to looking for evidence of the existence of a mood disorder, the initial psychiatric evaluation includes an assessment for the presence of an alcohol or substance use disorder or other somatic factors that may contribute to the disease process or complicate its treat-ment. The evaluation also requires a judgment about the safety of the patient and those around him or her and a decision about the appropriate setting for treatment (e.g., outpatient, day program, inpatient).

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The purpose of this guideline is to assist the clinician faced with the task of implementing a specific regimen for the treatment of a patient with bipolar disorder. It should be noted that many patients with bipolar disorder also suffer from comorbid psychiatric illnesses. Although this guideline provides considerations for managing comorbidity in the context of bipolar disorder, it is likely that the psychiatrist will also need to refer to treatment guidelines appropriate to other diagnoses.

This guideline concerns patients 18 years of age and older. Some comments regarding the treatment of bipolar disorder in children and adolescents can be found in sections III.B.4. (p. 14) and V.F. (p. 35) as well as in more definitive references (3).

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