New guidelines for bipolar disorders

The year 2009 may be allegedly called the “Bipolar Guidelines Year”, not only to avoid nasty references to the worldwide economic crisis, but to acknowledge the fact that the majority of the most influential treatment guidelines shall be publishing their updates and revised versions during this year. The past one (2008) was already important because the International Society for Bipolar Disorder (ISBD) Task Force's on bipolar disorder diagnosticguidelines published their reports, which included general proposals for changes for DSM-V and ICD-11 (Ghaemi et al. 2008), as well as specific suggestions for changes in diagnostic criteria concerning mania (Cassidy et al. 2008), bipolar depression (Mitchell et al. 2008), bipolar II disorder (Vieta and Suppes 2008), the bipolar spectrum (Phelps et al. 2008), rapid cycling (Bauer et al. 2008), paediatric bipolar disorder (Youngstrom et al. 2008), and schizoaffective disorder (Malhi et al. 2008). Now that the DSM-V working groups have reached a crucial point when specific changes in diagnostic categories and criteria will start to be discussed, it is timely to provide input from international societies, expert groups, and opinion leaders as regards to how the new classification should look like (Klein 2008; Kupfer et al. 2008; Möller 2008; Vieta 2008; First et al. 2009; Colom and Vieta, in press), and how to make it more valid (Phillips and Frank 2006; Vieta and Phillips 2007; Phillips and Vieta 2007; Pies in press). In 2008 as well, the European College of Neuropsychopharmacology (ECNP) published their consensus report on bipolar depression (Goodwin et al. 2008), and a further report on combination therapy with antipsychotics across several psychiatric conditions, including bipolar disorder, is expected for 2009. Furthermore, the International Consensus Group on Bipolar Depression Treatment Guidelines also updated their 2004 report (Calabrese et al. 2004) and the new one was published last year in the Journal of Clinical Psychiatry (Kasper et al. 2008).

Why is it precisely 2009 when most treatment guidelines updates will be coming out? Partly, by chance, but also because there have been many important treatment developments during the past 5 years or so that clearly deserve to be addressed and discussed in the context of traditional approaches and treatment options. The American Psychiatric Association (APA) guidelines, for instance, were lastly updated in 2002 (American Psychiatric Association, 2002) and the new version will be published soon in 2009 (American Psychiatric Association, in press). Seven critical years have gone through and this likely means very relevant changes in guideline content. The Texas medication algorithms were updated in 2005 (Suppes et al. 2005). The Canadian guidelines were published originally in 2005 and updated by the end of 2006 (Yatham et al. 2006), and the new update, containing important changes in recommendations for the treatment of mania, bipolar depression, and maintenance, is already in press in Bipolar Disorders (Yatham et al, in press). This new update, moreover, has been opened to non-Canadian experts designed by the ISBD and has thus become the first ISBD-endorsed treatment guideline. Other guidelines, such as the British Association of Psychopharmacology (Goodwin et al. 2003) or the NICE ones (National Institute for health and Clinical Excellence 2006), may need to be reviewed soon. Finally, the World Federation of Societies of Biological Psychiatry (WFSBP) has designed a Task Force to work on their new bipolar treatment guidelines version. The original ones were published in 3 separate papers addressing bipolar depression, mania, and maintenance therapy, in the World Journal of Biological Psychiatry in 2002, 2003, and 2004, respectively (Grunze et al. 2002, 2003, 2004). A strong effort is being developed to have the three parts published in 2009 (Grunze et al. in press a, Grunze et al. in press b, Grunze et al. in press c). These guidelines have gathered international experts and the latest data and developments and are aimed to address the evidence-based treatment of bipolar illness from a global, worldwide perspective, albeit their main focus is pharmacological treatment. Importantly, these and all the mentioned treatment guidelines clearly disclose all potential conflicts of interest. Although the pros and cons of treatment guidelines have been thoroughly debated (Fountoulakis et al. 2005), there is some evidence that their application may be helpful to clinicians and carry substantial benefits to the patients (Dennehy et al. 2005; Perlis 2007).

In summary, 2009 will bring us a great deal of consensus, insight, and indications on how to best treat people with bipolar disorder. The challenge, however, will be to be able to apply that guidance in a way which is effective, patient-friendly, and truly practical for better outcomes for our patients. There is an obvious gap between evidence base and clinical practice, and hopefully clinicians will be able to fill it with experience, common sense, and respect for patients’ choices.