Philip B Mitchell1. 1. AM, MBBS, MD, FRANZCP, FRCPsych is Scientia Professor and Head of the School of Psychiatry at the University of New South Wales; and Director of the Bipolar Disorders Clinic of the Black Dog Institute, Sydney, New South Wales.
Abstract
BACKGROUND: Bipolar disorder affects about 1% of Australians and impacts severely on relationships, careers and general functional capacity. General practitioners are central in the management of patients with bipolar disorder. OBJECTIVE: To update clinicians on the recognition, diagnosis and management of bipolar disorder in light of recent research. DISCUSSION: There is growing concern about the over-diagnosis of bipolar disorder, and increasing evidence that bipolar depression may present differently to unipolar depression. Antipsychotics are the initial agents of choice for the acute treatment of mania. For preventive treatment, lithium and atypical antipsychotics have the strongest evidence base. Lithium has been shown to be more effective than valproate. The main effect of lithium and most of the atypical antipsychotics is on prevention of manic relapse; only olanzapine and quetiapine also protect against depression. Lamotrigine is an agent with evidence for prevention of depressive relapse, but have minimal activity against mania. The role of antidepressants remains contentious, while there is strong support for quetiapine. Finally, there is growing evidence from randomised controlled trials of the benefit of psychological therapies in conjunction with medications.
BACKGROUND:Bipolar disorder affects about 1% of Australians and impacts severely on relationships, careers and general functional capacity. General practitioners are central in the management of patients with bipolar disorder. OBJECTIVE: To update clinicians on the recognition, diagnosis and management of bipolar disorder in light of recent research. DISCUSSION: There is growing concern about the over-diagnosis of bipolar disorder, and increasing evidence that bipolar depression may present differently to unipolar depression. Antipsychotics are the initial agents of choice for the acute treatment of mania. For preventive treatment, lithium and atypical antipsychotics have the strongest evidence base. Lithium has been shown to be more effective than valproate. The main effect of lithium and most of the atypical antipsychotics is on prevention of manic relapse; only olanzapine and quetiapine also protect against depression. Lamotrigine is an agent with evidence for prevention of depressive relapse, but have minimal activity against mania. The role of antidepressants remains contentious, while there is strong support for quetiapine. Finally, there is growing evidence from randomised controlled trials of the benefit of psychological therapies in conjunction with medications.