Introduction
These are the approved guidelines published by the South African Society of Psychiatrists to provide an overview on treatment and management of commonly diagnosed psychiatric illnesses. The guidelines include consensus recommendations, based on peer contribution and using the international evidence based guidelines that are suitable for the local South African health service.
Please note that parts of this guideline may be out of date, an update will be published as soon as it is available.
Bipolar disorder (BD) presents in different phases over time and is often complicated by comorbid conditions such as substance-use disorders and anxiety disorders. Treatment usually involves pharmacotherapy with combinations of different classes of medications and frequent medication revisions.
Since practice recommendations or treatment guidelines cannot fully summarise the myriad of presentations, they need to be used flexibly, taking into account the individual patient, the sociocultural context and the availability of treatment resources. The Medicines Control Council (MCC) in South Africa often lags behind other international regulatory agencies regarding the registration of medications with confirmed efficacy for indications in BD and therefore clinicians have to prescribe certain drugs off-label in the treatment of routine, difficult and treatment-resistant cases of BD.
In this guideline, levels of evidence derived from studies will be explored.[1] Evidence criteria include:
-
Level 1: meta-analysis or replicated double-blind (DB), randomised
controlled trial (RCT) with a placebo condition -
Level 2: at least one DB-RCT with active comparison condition or
placebo -
Level 3: prospective uncontrolled trial with at least ≥10 participants
-
Level 4: anecdotal reports or expert opinion. This guideline makes treatment recommendations:[1]
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First line: level 1 or level 2 evidence plus clinical support for safety and efficacy
-
Second line: level 3 evidence or higher plus clinical support for safety and efficacy
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Third line: level 4 evidence or higher plus clinical support for safety and efficacy
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Not recommended: level 1 or level 2 evidence for lack of efficacy.
Epidemiology of bipolar disorder pertinent to the treatment guideline[2-5]
Epidemiological statistics
For bipolar I disorder, the mean reported age of the first mood episode is 18.2 years, while the lifetime prevalence is 1%. For bipolar II disorder, the mean reported age of first mood episode is 20.3 years, while the lifetime prevalence is 1.1%. Bipolar I disorder affects men and women equally, while bipolar II disorder is more common in women.[3,4]
Illness characteristics
The first symptoms of BD often present at 15 - 19 years of age. The most likely first episode, and also predominant phase in the later stages of the illness, is depression. Suicide is 15 times more likely in BD patients compared to the general population, with as many as 7 - 15% of all bipolar sufferers committing suicide. Suicide is most likely to occur during mixed or depressive episodes.[5]