Bipolar Disorder Treatments: A New Guide to What Works

The highs and lows of bipolar disorder are challenging enough. Finding treatments that genuinely help during peaks, troughs and everything between them can add another layer of upheaval.

A living guide to bipolar disorder treatments

One of the most extensive reviews of bipolar disorder treatments across its different mood phases has now appeared in The BMJ. It is accompanied by a web-based tool intended to help doctors and patients identify the approaches most likely to suit them.

"Nearly half of individuals with bipolar disorder do not adhere to prescribed treatments, often because of perceived inefficacy, poor tolerability, or insufficient involvement in decision-making," the paper's authors write.

Each new piece of research shifts medical knowledge at least slightly, yet time pressures can make it hard for both doctors and patients to stay up to date. That matters because following medication plans and other treatments can be a matter of life or death for people living with bipolar disorder.

"Research on bipolar disorder treatment moves so quickly that it's nearly impossible to keep up," says clinical investigator and psychiatrist Marco Solmi, who works at The Ottawa Hospital and the University of Ottawa's mental health department.

The platform brings together findings from 77 existing meta-analyses, which combine the results of multiple studies to identify wider patterns. It rates bipolar treatments according to the certainty of the scientific evidence and their efficacy across the disorder's phases, including effects on symptoms, response and remission.

"We hope clinicians will be able to use the platform with their own patients to find the best balance between efficacy and side effects, according to each patient's needs," says Michele De Prisco, psychiatrist and researcher at the Hospital Clínic de Barcelona and the University of Barcelona.

"Using the platform and its integrated preference tool, clinician and patient can decide together which treatment to consider next."

What follows is a snapshot of the review's findings. The resource is designed to update in real time as research progresses.

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Treatments for depressive and manic phases

For adults in depressive phases, cariprazine, lurasidone, olanzapine and quetiapine performed particularly well across all three efficacy outcomes, with at least moderate-to-high scientific certainty. In other words, there is good evidence that they work effectively.

For manic phases, the review identified haloperidol and risperidone as having the strongest effects on symptoms and response, with high certainty for both measures - again, strong evidence of their effectiveness.

Risperidone also comes in a long-acting injectable form, which may assist patients during the periods between symptoms, known as the maintenance phase.

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Tamoxifen also stood out for mania, producing an effect size well beyond those of the other drug treatments. However, there is an important limitation.

The medicine is not yet approved to treat bipolar disorder. It is a hormone therapy used chiefly as a breast cancer medicine.

Early trials of tamoxifen have shown a lot of promise, but there is not yet enough evidence to rely on. As a hormone therapy, it will not suit every patient, and further research is clearly required.

Maintenance care and individual treatment decisions

For the maintenance phase of bipolar disorder - particularly interventions that may prevent acute phases or episodes - a non-drug approach emerged strongly. Group psychoeducation met all three efficacy outcomes with at least moderate scientific certainty.

"The only intervention supported by at least moderate certainty for the prevention of any episode, including depressive and manic episodes (although with only a small effect)… was group psychoeducation added to usual care pharmacological interventions," the authors report.

The researchers suggest this could work by improving how patients understand their illness, potentially supporting healthier lifestyle choices, circadian rhythms and adherence to pharmacological treatments.

Cognitive behavioural therapy likewise had evidence for improving symptoms and preventing relapses of mood episodes.

However, these findings are fixed at a particular point in time and do not account for what individual patients prefer. Meta-meta-analyses can show which options work best across a population, but cannot establish what will necessarily be most effective for your body or how treatments may interact with everything else happening in your life.

Related: Bipolar Disorder Linked to a Higher Risk of Early Death Than Smoking

The essential work of bipolar treatment takes place between a doctor and patient, with care tailored to individual needs.

The online tool is intended, over the longer term, to continuously incorporate newly released research. This would allow clinicians to use population-level evidence while seeking the most suitable treatment for each patient's personal circumstances.

"This living review is a foundation for continuously improving clinical care in bipolar disorder, being rapidly adaptable as new evidence emerges," the authors conclude.

The next step is to determine how effectively the tool performs in real-world settings.

The research was published in The BMJ.

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This article was fact-checked by Fiona MacDonald and edited by Rebecca Dyer. Although we take pride in our process, we are only human. If you spot an error, please let us know.