FLORIDA BEST PRACTICE MEDICATION GUIDELINES FOR BIPOLAR DISORDER By Terence A. Ketter, M.D, Po W. Wang, M.D.

TABLE A–1.Principles of practice for adults

1.Careful diagnostic evaluation

•Bipolarity must be assessed in patients presenting with depression

•Suicidality must be carefully assessed

•Psychiatric and physical comorbidities must be carefully assessed

•Substance abuse must be evaluated and addressed

2.Measurement-based care

•Treatment targets need to be precisely defined

•Effectiveness and safety/tolerability of medication treatment must be

systematically assessed by methodical use of appropriate rating scales and

side-effect assessment protocols

• For schizophrenia:

•Clinical Global Impression Scale (CGI) and

•Brief Psychiatric Rating Scale (BPRS)

• For major depressive disorder:

•Hamilton Rating Scale for Depression (HRSD) and

•Patient Health Questionnaire (PHQ)

•Montgomery-Åsberg Depression Rating Scale (MADRS) as an acceptable

alternative to HRSD

• For bipolar disorder:

•Young Mania Rating Scale for Bipolar Disorder (YMRS)

•Hamilton Rating Scale for Depression (HRSD)

•Encourage self-rating scale for depression such as

– Beck Depression Inventory (BDI)

– 16-Item Quick Inventory of Depression Symptomatology (QIDS-SR16)

3.Collaborative treatment decision making

•Ongoing calibration of expected outcomes and progression toward goals

TABLE A–2.Treatment of bipolar I disorder adult acute mania

Level 0: Complete assessment

Level 1: If not treatment resistant and not very severe

•(May start at level 2 if treatment resistant or very severe)

–Aripiprazole, lithium, olanzapine, quetiapine, risperidone, valproate, or

ziprasidone monotherapy

–Carbamazepine (accounting for drug interactions) is an alternative monotherapy

Level 2: If level 1 is not effective

•Two-drug combination of lithium plus valproate, or [lithium or valproate] plus

level 1 second-generation antipsychotic

•Two-drug combination with carbamazepine (accounting for drug interactions)

with level 1 drugs an alternative

Level 3: If levels 1 and 2 ineffective or not tolerated(*)

•Different two-drug combination of level 1 drugs (but not two antipsychotics) and

may include oxcarbazepine

Level 4: If levels 1, 2, 3 ineffective or not tolerated (*)

•Two-drug or three-drug combinations of level 1, 2, 3 drugs, may include first-

generation antipsychotic (but not two antipsychotics)

•Example:

–Lithium + (valproate, carbamazepine, or oxcarbazepine) + antipsychotic

•Electroconvulsive therapy

•Clozapine

TABLE A–3.Treatment of bipolar I disorder adult acute depression

Level 0:

•Comprehensive assessment

Level 1:

•Olanzapine-fluoxetine combination or quetiapine monotherapy

•Two-agent combination of (bupropion or SSRI) with (carbamazepine, lithium, or

valproate)

Level 2: If level 1 ineffective or not tolerated(a)

•Any combinations of level 1 treatments

–Also combinations of (MAOI, SNRI, other antidepressant) with (lithium,

valproate, second-generation antipsychotics)

–Lamotrigine or olanzapine monotherapy

- Risperidone or ziprasidone monotherapy is an alternative

–Antipsychotic (SGA or FGA) combined with either lamotrigine, lithium, or

valproate

Level 3: If levels 1 and 2 ineffective or not tolerated (a)

•Adjunctive clozapine, inositol, pramipexole, stimulants, or thyroid hormones added

to existing mood stabilizer therapy

TABLE A–4.Bipolar maintenance therapy

Level 1: Continue effective and well-tolerated level 1 treatment for acute mania or acute

depression

–If frequent, recent or severe mania

- Aripiprazole, lithium, olanzapine, valproate

–If frequent, recent, or severe depression

- Lamotrigine, lithium, olanzapine, valproate

Level 2: If level 1 ineffective or not tolerated

•Monotherapy with carbamazepine, quetiapine, risperidone, ziprasidone (in absence

of acute response data)

•Lithium + valproate or carbamazepine or lamotrigine

•Lithium or valproate + antipsychotic (SGA or FGA)

Level 3: If levels 1 and 2 ineffective or not tolerated

•Combinations of other level 1 or 2 acute mania or depression agents

Notes:

FGA=first-generation antipsychotic;

SGA = second-generation antipsychotic;

MAOI=monoamine oxidase inhibitor;

SNRI=serotonin-norepinephrine reuptake inhibitor;

SSRI=selective serotonin reuptake inhibitor

ECT=electroconvulsive therapy;

(*)Number of iterations at each level and adjunctive treatment(s) to be determined by clinician

judgment and patient needs.

(a) Number of iterations at each level and adjunctive treatment(s) to be determined by clinician

judgment and patient needs.

Consulted Sources:

- Handbook of Diagnosis and Treatment of Bipolar Disorders by Terence A. Ketter, M.D., Appendix A

-“Florida Best Practice Medication Guidelines: Principles of Practice for Adults.” Available at

http://flmedicaidbh.fmhi.usf.edu/recommended_adult_guidelines.htm. Tampa, FL, University of South Florida.

-“Florida Best Practice Medication Guidelines for Treatment of Bipolar I Disorder Adult Acute Mania.”Available at http://flmedicaidbh.fmhi.usf.edu/recommended_adult_

guidelines.htm. Tampa, FL, University of South Florida

- “Florida Best Practice Medication Guidelines for Treatment of Bipolar I Disorder Adult Acute Depression.” Available at http://flmedicaidbh.fmhi.usf.edu/recommended_

adult_guidelines.htm. Tampa, FL, University of South Florida

- “Florida Best Practice Medication Guidelines for Bipolar Maintenance Therapy After Depressive Episodes.” Available at http://flmedicaidbh.fmhi.usf.edu/recommended_

adult_guidelines.htm. Tampa, FL, University of South Florida