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Pharmacological treatment of adult bipolar disorder

Molecular Psychiatry volume 24, pages 198–217 (2019)Cite this article

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Abstract

We summarize evidence supporting contemporary pharmacological treatment of phases of BD, including: mania, depression, and long-term recurrences, emphasizing findings from randomized, controlled trials (RCTs). Effective treatment of acute or dysphoric mania is provided by modern antipsychotics, some anticonvulsants (divalproex and carbamazepine), and lithium salts. Treatment of BD-depression remains unsatisfactory but includes some modern antipsychotics (particularly lurasidone, olanzapine + fluoxetine, and quetiapine) and the anticonvulsant lamotrigine; value and safety of antidepressants remain controversial. Long-term prophylactic treatment relies on lithium, off-label use of valproate, and growing use of modern antipsychotics. Lithium has unique evidence of antisuicide effects. Methods of evaluating treatments for BD rely heavily on meta-analysis, which is convenient but with important limitations. Underdeveloped treatment for BD-depression may reflect an assumption that effects of antidepressants are similar in BD as in unipolar major depressive disorder. Effective prophylaxis of BD is limited by the efficacy of available treatments and incomplete adherence owing to adverse effects, costs, and lack of ongoing symptoms. Long-term treatment of BD also is limited by access to, and support of expert, comprehensive clinical programs. Pursuit of improved, rationally designed pharmacological treatments for BD, as for most psychiatric disorders, is fundamentally limited by lack of coherent pathophysiology or etiology.

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Acknowledgements

Supported by a grant from the Bruce J. Anderson Foundation and by the McLean Private Donors Psychiatry Research Fund (to RJB), and an award from the Aretæus Foundation of Rome (to LT). Sources of support had no influence on the conduct or reporting of this review.

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Authors and Affiliations

  1. International Consortium for Bipolar & Psychotic Disorders Research, Mailman Research Center, McLean Hospital, 115 Mill Street, Belmont, MA, 02478, USA

    Ross J. Baldessarini

  2. Department of Psychiatry, Harvard Medical School, 25 Shattuck Street, Boston, MA, USA

    Ross J. Baldessarini

  3. Lucio Bini Mood Disorders Centers, Via Cavalcanti 28, 0918, Cagliari and Via Crescenzio 42, Rome, 00193, Italy

    Leonardo Tondo

  4. Department of Psychiatry, Queen’s University, 15 Arch Street, Kingston, ON, K763N6, Canada

    Gustavo H. Vázquez

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  1. Ross J. Baldessarini
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Baldessarini, R.J., Tondo, L. & Vázquez, G.H. Pharmacological treatment of adult bipolar disorder. Mol Psychiatry 24, 198–217 (2019). https://doi.org/10.1038/s41380-018-0044-2

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