Pharmacotherapeutic interventions for bipolar disorder type II: addressing multiple symptoms and approaches with a particular emphasis on strategies in lower and middle-income countries

ABSTRACT

Introduction: Appropriately managing mental disorders is a growing priority across countries in view of the impact on morbidity and mortality. This includes patients with bipolar disorders (BD). Management of BD is a concern as this is a complex disease with often misdiagnosis, which is a major issue in lower and middle-income countries (LMICs) with typically a limited number of trained personnel and resources. This needs to be addressed.

Areas covered: Medicines are the cornerstone of managing patients with Bipolar II across countries including LMICs. The choice of medicines, especially antipsychotics, is important in LMICs with high rates of diabetes and HIV. However, care is currently compromised in LMICs by issues such as the stigma, cultural beliefs, a limited number of trained professionals and high patient co-payments.

Expert opinion: Encouragingly, some LMICs have introduced guidelines for patients with BD; however, this is very variable. Strategies for the future include addressing the lack of national guidelines for patients with BD, improving resources for mental disorders including personnel, improving medicine availability and patients’ rights, and monitoring prescribing against agreed guidelines. A number of strategies have been identified to improve the treatment of patients with Bipolar II in LMICs, and will be followed up.

KEYWORDS:

• Bipolar disorders
• bipolar disorder type II
• lower- and middle-income countries
• health policies
• treatment
• pharmaceuticals
• differential diagnosis

Article Highlights

• There are challenges to appropriately manage patients with mental disorders in lower and middle-income countries (LMICs) due to limited government spending and a limited number of trained personnel compared with high-income countries.

• The prevalence of bipolar disease (BD) has increased appreciably in recent years and is now one of the most disabling diseases worldwide.

• The management of BD disease is challenging as it can be difficult to differentiate between the different BD states and between unipolar depresssion and Bipolar II (BP-II), and there can be appreciable delays in diagnosis especially in LMICs.

• The management of BP-II includes both pharmacological (lithium, anticonvulsants, antipsychotics, and antidepressants) and non-pharmacological approaches; however, there is currently variable availability of standard treatment guidelines in LMICs to guide patient care and the prescribing of lithium will depend on available monitoring facilities.

• The choice of antipsychotic is particularly important in sub-Saharan Africa with high rates of overweight, obesity and Type 2 diabetes, with care also needed in patients with HIV and BD as some treatments for HIV can increase mental disorders.

This box summarizes key points contained in the article.

Declaration of interest

Marianne Van-De-Lisle is employed by NHS Lothian, Ruaraidh Hill advises the UK National Health Service while Amos Massele and Philip Opondo advise the Botswanan Ministry of Health. Israel Sefah is employed by the Ghana Health Service while Kristina Garuoliene is employed by the Lithuanian Ministry of Health. Additionally, Tanveer Ahmed Khan and Shahzad Hussain are employed by the National Institute of Health, Pakistan while James Mwanza advises the Zambian Ministry of Health. Furthermore, Corrado Barbui is an advisor to the World Health Organization. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This manuscript has not been funded.