Korean Medication Algorithm Project for Bipolar Disorder: third revision

Figures & data

Table 1 Initial treatment strategies for acute manic/hypomanic episode

	First-line treatment	High second-line treatment	Low second-line treatment
Euphoric mania	MS plus AAP* MS monotherapy	AAP monotherapy	MS plus TAP
Mixed mania	MS plus AAP	MS monotherapy AAP monotherapy	MS plus TAP
Psychotic mania	MS plus AAP* AAP monotherapy	MS plus TAP	MS monotherapy TAP monotherapy
Hypomania	MS monotherapy AAP monotherapy	MS plus AAP	TAP monotherapy MS plus TAP

Note:

* Treatment of choice.

Abbreviations: AAP, atypical antipsychotics; MS, mood stabilizer; TAP, typical antipsychotics.

Figure 1 Korean Medication Algorithm for Bipolar Disorder 2014: manic episode.

Notes: Electroconvulsive therapy and benzodiazepine can be applied by clinician’s decision at any time. *Treatment of choice. Agents separated by “/” have similar preference. An agent followed by a second agent in parentheses indicates that the first agent has significantly more preference than the second agent.
Abbreviations: AAP, atypical antipsychotics; CZP, clozapine; LIT, lithium; mono, monotherapy; MS, mood stabilizer; VAL, valproic acid.

Figure 2 Korean Medication Algorithm for Bipolar Disorder 2014: depressive episode.

Notes: Electroconvulsive therapy and benzodiazepine can be applied by clinician’s decision at any time. Agents separated by “/” have similar preference. An agent followed by a second agent in parentheses indicates that the first agent has significantly more preference than the second agent.
Abbreviations: AAP, atypical antipsychotics; AD, antidepressant; ECT, electroconvulsive therapy; LMT, lamotrigine; mono, monotherapy; MS, mood stabilizer (valproic acid, lithium, carbamazepine).

Table 2 Initial treatment strategies for acute depressive episode

	First-line treatment	Second-line treatment	Third-line treatment
Mild	MS/AAP monotherapy	LTG monotherapy AAP plus MS/LTG MS plus AD/LTG AAP plus AD AAP plus MS plus LTG/AD AAP plus AD plus LTG	ECT
Moderate and nonpsychotic severe depression	MS plus AAP/AD	MS/AAP/LTG monotherapy AAP plus LTG MS plus LTG AAP plus AD MS plus AAP plus AD/LTG AAP plus AD plus LTG ECT
Psychotic severe depression	AAP plus MS/AD/LTG	MS/AAP/LTG monotherapy
	MS plus AAP plus AD/LTG	MS plus AD/LTG
	AAP plus AD plus LTG	ECT

Abbreviations: AAP, atypical antipsychotics; AD, antidepressant; ECT, electroconvulsive therapy; LTG, lamotrigine; MS, mood stabilizer.

Table 3 Next step treatment strategies when initial treatment for bipolar depression was inadequate

	First-line strategies	Second-line strategies	Third-line strategies
MS monotherapy
No response	Add AAP Add LTG	Change to LTG Change to another MS Add AD Add MS Add stimulant Add TAP	Add thyroid hormone
Partial response	Add AAP Add LTG Add MS	Add AD Add stimulant
AAP monotherapy
No response	Add LTG Add MS Change to another AAP	Change AAP Add AD Add stimulant	Change to TAP Add thyroid hormone
Partial response	Add MS Add LTG	Change to another AAP Add AD Add stimulant
LTG monotherapy
Inadequate response	Add AAP Add MS	Add AD Change to MS Add stimulant Add TAP	Add thyroid hormone
MS plus AP combination
No response	Add LTG Change to another MS Change to LTG	Add AD Add MS Add AAP Add AP Add stimulant	Add TAP
Partial response	Add LTG Add AAP Add MS	Add AD Change to LTG Change to another MS Change AP Add stimulant
MS plus AD combination
No response	Add AAP Add LTG Change to LTG Change to another MS	Change to another AD Add MS Add AD Add stimulant Add TAP	Add thyroid hormone
Partial response	Add AAP Add LTG	Add MS Change to LTG Change to another MS Change other AD Add AD Add stimulant Add TAP
AP plus LTG combination
Inadequate response	Add MS	Add AAP	Add TAP
	Add AD	Add stimulant	Add thyroid hormone

Abbreviations: AP, antipsychotics; AAP, atypical AP; AD, antidepressant; LTG, lamotrigine; MS, mood stabilizer; TAP, typical AP.

Table 4 Initial treatment strategies for bipolar disorder in children and adolescents

	First-line treatment	High second-line treatment	Low second-line treatment
Children
Mania	MS plus AAP AAP monotherapy	MS monotherapy	MS plus other AAP MS plus AAP plus LTG I&O
Depression		MS plus AAP/AD MS/AAP monotherapy LTG plus AAP/MS	MS plus AAP plus AD/LTG MS plus AP plus AD LTG monotherapy AAP plus AD MS plus AP AP/LTG plus AD MS plus AAP plus LTG plus AD I&O
Adolescents
Mania	MS plus AAP	AAP/MS monotherapy MS plus other AAP	MS plus LTG/TAP MS plus AAP plus LTG
Depression		AAP monotherapy MS plus AAP/AD AAP plus AD MS monotherapy LTG plus MS/AAP	LTG monotherapy LTG plus AD AP plus MS MS plus AP plus AD MS plus AAP plus AD/LTG MS plus AAP plus LTG plus AD I&O

Note: Bold: no consensus.

Abbreviations: AP, antipsychotics; AAP, atypical AP; AD, antidepressant; I&O, interview and observation; LTG, lamotrigine; MS, mood stabilizer; TAP, typical AP.

Table 5 Initial treatment strategies for geriatric bipolar disorder

	First-line treatment	High second-line treatment	Low second-line treatment
Manic episode	AAP/MS monotherapy MS plus AAP		MS plus LTG/TAP/other AAP MS plus LTG plus AAP/other AAP/TAP ECT TAP monotherapy
Depressive episode	AAP monotherapy AAP plus MS/LTG	MS/LTG monotherapy MS plus LTG/AD	TAP/AD monotherapy AD plus AAP/LTG TAP plus MS/AD MS plus AD plus TAP MS plus AAP plus LTG/AD MS plus AAP plus LTG plus AD ECT

Note: Bold: no consensus.

Abbreviations: AAP, atypical antipsychotics; AD, antidepressant; ECT, electroconvulsive therapy; LTG, lamotrigine; MS, mood stabilizer; TAP, typical antipsychotics.