Texas Medical Algorithms Project (TMAP)

(August 2005)

This project (here is their website) has been underway for more than 5 years. There are three “algorithms” — lists of suggested steps: one each for manic symptoms, depression symptoms, and mixed states. So far, all these algorithms are specifically for Bipolar I. There are no separate suggestions for Bipolar II.

The TMAP 2005 version for bipolar depressionSuppes includes several substantial changes. Although now are much closer to my own approach, and thus striking me as very appropriate, these changes have already aroused controversy: in the same journal a commentary wondered whether there really was enough evidence to justify the changes made,Perlis and the TMAP authors note a “minority opinion” would have kept antidepressants as an earlier step. These reflect the continuing controversy over the role of antidepressants in bipolar treatment, as summarized¬†on my Antidepressant Controversies page.

There are three major changes from the 2000 version for bipolar depression:

  • lamotrigine appears as a first step;
  • quetiapine (Seroquel) or olanzapine/fluoxetine combination (Symbyax) appear as the second step; and
  • antidepressants have been demoted to a 4th step, from step 2.

as shown here:


Stages 5 and 6 are now combined. In this stage, omega-3’s, acupuncture and hormones have been removed; other atypical antipsychotics appear there as before, now along with oxcarbazepine and pramipexole (formerly dopamine agonists generally, and stimulants).