Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) 2018 guidelines for the management of patients with bipolar disorder

Abstract

The Canadian Network for Mood and Anxiety Treatments (CANMAT) previously published treatment guidelines for bipolar disorder in 2005, along with international commentaries and subsequent updates in 2007, 2009, and 2013. The last two updates were published in collaboration with the International Society for Bipolar Disorders (ISBD). These 2018 CANMAT and ISBD Bipolar Treatment Guidelines represent the significant advances in the field since the last full edition was published in 2005, including updates to diagnosis and management as well as new research into pharmacological and psychological treatments. These advances have been translated into clear and easy to use recommendations for first, second, and third- line treatments, with consideration given to levels of evidence for efficacy, clinical support based on experience, and consensus ratings of safety, tolerability, and treatment-emergent switch risk. New to these guidelines, hierarchical rankings were created for first and second- line treatments recommended for acute mania, acute depression, and maintenance treatment in bipolar I disorder. Created by considering the impact of each treatment across all phases of illness, this hierarchy will further assist clinicians in making evidence-based treatment decisions. Lithium, quetiapine, divalproex, asenapine, aripiprazole, paliperidone, risperidone, and cariprazine alone or in combination are recommended as first-line treatments for acute mania. First-line options for bipolar I depression include quetiapine, lurasidone plus lithium or divalproex, lithium, lamotrigine, lurasidone, or adjunctive lamotrigine. While medications that have been shown to be effective for the acute phase should generally be continued for the maintenance phase in bipolar I disorder, there are some exceptions (such as with antidepressants); and available data suggest that lithium, quetiapine, divalproex, lamotrigine, asenapine, and aripiprazole monotherapy or combination treatments should be considered first-line for those initiating or switching treatment during the maintenance phase. In addition to addressing issues in bipolar I disorder, these guidelines also provide an overview of, and recommendations for, clinical management of bipolar II disorder, as well as advice on specific populations, such as women at various stages of the reproductive cycle, children and adolescents, and older adults. There are also discussions on the impact of specific psychiatric and medical comorbidities such as substance use, anxiety, and metabolic disorders. Finally, an overview of issues related to safety and monitoring is provided. The CANMAT and ISBD groups hope that these guidelines become a valuable tool for practitioners across the globe.

Figure 1

Hierarchical rankings of treatment recommendations: How were they arrived at? [Colour figure can be viewed at http://wileyonlinelibrary.com]

Figure 2

Lithium and lamotrigine as first‐line agents for bipolar I depression: Summary of evidence> [Colour figure can be viewed at http://wileyonlinelibrary.com]

Figure 3

Armodafinil and modafinil as third‐line agents for bipolar I depression: Summary of evidence [Colour figure can be viewed at http://wileyonlinelibrary.com]

Figure 4

Divalproex as a first‐line maintenance therapy for bipolar I disorder: Summary of evidence RCT, randomized controlled trial [Colour figure can be viewed at http://wileyonlinelibrary.com]

Figure 5

Lithium as a second‐line agent for bipolar II depression: Summary of evidence. BDI, bipolar disorder type I; BDII, bipolar disorder type II; BDNOS, bipolar disorder not otherwise specified; RCT, randomized controlled trial [Colour figure can be viewed at http://wileyonlinelibrary.com]

Figure 6

Antidepressants for bipolar II depression: What is their role? BDI, bipolar disorder type I; BDII, bipolar disorder type II; ISBD, International Society for Bipolar Disorders; MDD, major depressive disorder; RCT, randomized controlled trial [Colour figure can be viewed at http://wileyonlinelibrary.com]

Figure 7

Lamotrigine as a second‐line agent for bipolar II depression: Summary of evidence BDI, bipolar disorder type I; BDII, bipolar disorder type II; RCT, randomized controlled trial [Colour figure can be viewed at http://wileyonlinelibrary.com]

Figure 8

Treatments for pediatric bipolar depression: Summary of evidence [Colour figure can be viewed at http://wileyonlinelibrary.com]

Figure 9

What is the role of primary treatments for anxiety disorders in treating co‐morbid anxiety in bipolar disorder? RCT, randomized controlled trial [Colour figure can be viewed at http://wileyonlinelibrary.com]