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

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OVERVIEW OF GUIDELINE DEVELOPMENT PROCESS

This document is a practical guide to the management of patients-primarily adults 18 years of age and older with bipolar disorder and represents a synthesis of current scientific knowledge and rational clinical practice. This guideline strives to be as free as possible of bias toward any theoretical approach to treatment.

This practice guideline was developed under the auspices of the Steering Committee on Practice Guidelines. The development process is detailed in a document available from the APA Department of Quality Improvement and Psychiatric Services: the "APA Guideline Development Process." Key features of this process include the following:

• A comprehensive literature review and development of evidence tables.
• Initial drafting by a work group that included psychiatrists with clinical and research expertise in bipolar disorder.
• The production of multiple drafts with widespread review; seven organizations and more than 40 individuals submitted significant comments.
• Approval by the APA Assembly and Board of Trustees.
• Planned revisions at regular intervals.

A computerized search of the relevant literature from MEDLINE and PsycINFO was conducted. Sources of funding were not considered when reviewing the literature.

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The first literature search was conducted by searching MEDLINE and PsycINFO for the period from 1992 to 2000. Key words used were "bipolar disorder," "bipolar depression," "mania," "mixed states," "mixed episodes," "mixed mania," "antimanic," "hypomanic," "hypomania," "manic depression," "prophylactic," "pharmacotherapy," "mood stabilizers," "mood-stabilizing," "rapid cycling," "maintenance," "continuation," "child and adolescent," "antidepressants," "valproate," "lithium," "carbamazepine," "olanzapine," "risperidone," "gabapentin," "topiramate," "lamotrigine," "clonazepam," "divalproex," "psychotherapy," "family therapy," "psychoeducation," "course," "epidemiology," "comorbidity," "anxiety," "anxiety disorders," "attention deficit," "catatonia," "elderly," "family history," "gender," "general medical conditions," "life events," "personality disorders," "pregnancy," "psychosis," "stress," "substance-related disorders," "suicide," "homicide," and "violence." A total of 3,382 citations were found.

An additional MEDLINE search for the period from 1992 to 2001 used the key words "genetic counseling," "family functioning," "cross-cultural issues," and "pharmacokinetics." A total of 122 citations were found. A search on PubMed was also conducted through 2001 that used the search terms "electroconvulsive," "intravenous drug abuse," "treatment response," "pharmacogenetic," "attention deficit disorder," "violence," "aggression," "aggressive," "suicidal," "cognitive impairment," "sleep," "postpartum," "ethnic," "racial," "metabolism," "hyperparathyroidism," "overdose," "toxicity," "intoxication," "pregnancy," "breast-feeding," and "lactation."

Additional, less formal, literature searches were conducted by APA staff and individual members of the work group on bipolar disorder.

The recommendations are based on the best available data and clinical consensus with regard to a particular clinical decision. The summary of treatment recommendations is keyed according to the level of confidence with which each recommendation is made. In addition, each reference is followed by a letter code in brackets that indicates the nature of the supporting evidence.

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