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Background: A panel
consisting of academic psychiatrists and pharmacist administrators of
the Texas Department of State Health Services (formerly Texas Department
of Mental Health and Mental Retardation), community mental health
physicians, advocates, and consumers met in May 2004 to review new
evidence in the pharmacologic treatment of bipolar I disorder (BDI). The
goal of the consensus conference was to update and revise the current
treatment algorithm for BDI as part of the Texas Implementation of
Medication Algorithms, a statewide quality assurance program for the
treatment of major psychiatric illness. The guidelines for evaluating
possible medications, the criteria for selection and ranking, and the
updated algorithms are described.
Method: Principles from
previous consensus conferences were reviewed and amended. Medication
algorithms for the acute treatment of hypomanic/manic or mixed and
depressive episodes in BDI were developed after examining recent
efficacy and safety and tolerability data. Recommendations for
maintenance treatments were developed.
Results: The panel
updated the 2 primary algorithms (hypomanic/manic/mixed and depressive)
based on clinical evidence for efficacy, tolerability, and safety
developed since 2000. Expert consensus was utilized where clinical
evidence was limited. Prevention of new episodes or prophylaxis
treatment recommendations were developed based on recent data from
longer-term trials. Maintenance recommendations are provided as levels
versus a specified staged algorithm, as for acute treatment, due to the
relatively limited database to inform treatment.
Conclusions: These
algorithms for the treatment of BDI represent the recommendations based
on the most recent evidence available. These recommendations are meant
to provide a framework for clinical decision making, not to replace
clinical judgment. As with any algorithm, treatment practices will
evolve beyond the recommendations of this consensus conference as new
evidence and additional medications become available.
(J Clin Psychiatry
2005;66:870-886)
Received Dec. 29, 2004; accepted
April 20, 2005. From the Department of Psychiatry, the University of
Texas Southwestern Medical Center, Dallas (Dr. Suppes); the Department
of Psychological Science, Purdue University, West Lafayette, Ind. (Dr.
Dennehy); the Department of Psychiatry, the University of Texas Medical
Branch, Galveston (Dr. Hirschfeld); the Department of Psychiatry and
Biobehavioral Sciences, Mood Disorder Research Program, University of
California, Los Angeles, School of Medicine, Los Angeles (Dr. Altshuler);
the Department of Psychiatry, the University of Texas Health Science
Center, San Antonio (Dr. Bowden); the Department of Psychiatry, Case
Western Reserve University School of Medicine, Cleveland, Ohio (Dr.
Calabrese); College of Pharmacy, the University of Texas at Austin and
the Texas Department of State Health Services, Austin (Dr. Crismon); the
Department of Psychiatry and Behavioral Sciences, Stanford University
School of Medicine, Stanford, Calif. (Dr. Ketter); the Department of
Psychiatry, Harvard Medical School, Boston, Mass. (Dr. Sachs); and the
Mental Sciences Institute, the University of Texas Health Science
Center, Houston (Dr. Swann).
Financial disclosure appears at the
end of the article.
Acknowledgments appear at the end of
the article.
Corresponding author and reprints:
Trisha Suppes, M.D., Ph.D., Associate Professor of Psychiatry,
University of Texas, Southwestern Medical Center at Dallas, 5323 Harry
Hines Boulevard, Dallas, TX 75390-9121 (e-mail:
trisha.suppes@utsouthwestern.edu).
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