Treating bipolar disorder - Evidence-based guidelines for family medicine

OBJECTIVE To provide an evidence-based summary of medications commonly used for bipolar disorders and a practical approach to managing bipolar disorders in the office. QUALITY OF EVIDENCE Articles from 1990 to 2003 were selected from MEDLINE using the key words "bipolar disorder," "antiepileptics," "antipsychotics," "antidepressants," and "mood stabilizers." Good-quality evidence for many of these treatments comes from randomized trials. Lithium, divalproex, carbamazepine, lamotrigine, oxcarbazepine, and some novel antipsychotics all have level I evidence for treating various aspects of the disorder. MAIN MESSAGE Treatment of bipolar disorder involves three therapeutic domains: acute mania, acute depression, and maintenance. Lithium has been a mainstay of treatment for some time, but antiepileptic drugs like divalproex, carbamazepine, and lamotrigine, along with novel antipsychotic drugs like olanzapine, risperidone, and quetiapine, alone or in combination, are increasingly being used successfully to treat acute mania and to maintain mood stability. CONCLUSION Bipolar disorder is more common in family practice than previously believed. Drug treatments for this complex disorder have evolved rapidly over the past decade, radically changing its management. Treatment now tends to be very successful.