Expert Guidelines for Bipolar Treatment

(updated 12/2014)


So-and-so suggests Treatment A.  But you’ve heard about Treatment B.  Or maybe you are just not so sure So-and-so knows what he’s doing. Isn’t there an official website that describes bipolar treatment? Well, sort of.

Different international bodies produce updated guidelines every few years. They tend to be very general: they don’t specify exactly which treatment to use. Instead they say that Options A, B, C and D are all “first line”. That means So-and-so is correct to offer A, but could also offer B through D.

(Why didn’t you get told about the latter three, then? That’s what this site is for, to help you learn about the options you have.  More about details and pro’s and con’s than I or most providers will have time to review with you.  But if you read my Treatment page, you’re still stuck with just one voice; how do you know if you can trust it? It would be nice to know if I agree with the rest of the international community of mood specialists…)

But guidelines are also rather technical.  You could pore your way through technical charts and algorithms (which is fine by me if you can handle it; I’ll show you one).  Or you can just ask: what does everyone seem to agree on and where are the controversies? Allow me to outline those for you.

Agreements and Disagreements


1. Start with a mood stabilizer, avoid antidepressants (at least initially), and use the bipolar-specific psychotherapies if you can access them.

2. The goal is mood stability, not just fixing the mood state you’re in when you start. That means focusing on mood stabilizers, not just treating today’s mood with whatever might be needed for that alone.


a) When to use antidepressants, if ever.  The most recent guidelines from the International Society for Bipolar Disorders suggest avoiding antidepressants in all but a few situations. That’s much more like what I and those others (Nassir Ghaemi, Tam Kelly, Roger Sparhawk, Bob Caldwell, and more – all ISBD members) have been saying for years, so we’re pleased to see movement in our direction.

b) When to use antipsychotics. All of them are antimanic but only some are antidepressant. Those that do both can fairly be regarded as “mood stabilizers”. But should one try to avoid them because of their weight/glucose/cholesterol risks? I think so; the experts, who in my opinion must live too far up in ivory towers, do not seem to think so as much.

Recent guidelines

There are 2013-updated guidelines from the Canadian Network (CANMAT) and the International Society for Bipolar Disorders (ISBD). If you’re really new to bipolar treatment and skeptical of anyone except a panel of international experts (that’s good), the CANMAT/ISBD 2013 guidelines are a very reasonable place to start.

Finally, before you head into those guidelines or into my Treatment page (mine’s simpler but very consistent with CANMAT), here are some slides depicting the ISBD’s stance on antidepressants.  The good news is that the ISBD and CANMAT also agree on the three main medications for bipolar depression.  Me too.

ISBD Antidepressant Guidelines

First, I’ll show you my simplification of the ISBD paper.  But right below you’ll find a word-for-word version from the ISBD so you can make sure I didn’t fudge the translation.

Acute depression
  1. Okay if previous positive response
  1. Avoid if > 2 manic symptoms
  1. Avoid in mixed states.
  1. Avoid if history of predominantly mixed states
  1. Avoid if history of rapid cycling
  1. Avoid if previously induced hypomania/mania or mixed states
  1. Okay if relapse after stopping
  1. Avoid in Bipolar I
Induced mixed, rapid cycling, hypomania/mania
  1. Stop (monitor closely for the emergence of these)
Drug type 10.  Avoid SNRI or TCA

The word-for-word version ISBD:

Acute treatment
  1. Adjunctive antidepressants may be used for an acute bipolar I or II depressive episode when there is a history of previous positive response to antidepressants.
  1. Adjunctive antidepressants should be avoided for an acute bipolar I or II depressive episode with two or more concomitant core manic symptoms in the presence of psychomotor agitation or rapid cycling.
Maintenance treatment
  1. Maintenance treatment with adjunctive antidepressants may be considered if a patient relapses into a depressive episode after stopping antidepressant therapy.
  1. Antidepressant monotherapy should be avoided in bipolar I disorder.
  1. Antidepressant monotherapy should be avoided in bipolar I and II depression with two or more concomitant core manic symptoms.
Switch to mania, hypomania, or mixed states and rapid cycling
  1. Bipolar patients starting antidepressants should be closely monitored for signs of hypomania or mania and increased psychomotor agitation, in which case antidepressants should be discontinued.
  1. The use of antidepressants should be discouraged if there is a history of past mania, hypomania, or mixed episodes emerging during antidepressant treatment.
  1. Antidepressant use should be avoided in bipolar patients with a high mood instability (i.e., a high number of episodes) or with a history of rapid cycling.
Use in mixed states
  1. Antidepressants should be avoided during manic and depressive episodes with mixed features.
10. Antidepressants should be avoided in bipolar patients with predominantly mixed states.
11. Previously prescribed antidepressants should be discontinued in patients currently experiencing mixed states.