The Canadian Network for Mood and Anxiety Treatments (CANMAT) previously published treatment guidelines for bipolar disorder in 2005, along with international commentaries and subsequent updates in 2007, 2009, and 2013. The last two updates were published in collaboration with the International Society for Bipolar Disorders (ISBD). These 2018 CANMAT and ISBD Bipolar Treatment Guidelines represent the significant advances in the field since the last full edition was published in 2005, including updates to diagnosis and management as well as new research into pharmacological and psychological treatments. These advances have been translated into clear and easy to use recommendations for first, second, and third- line treatments, with consideration given to levels of evidence for efficacy, clinical support based on experience, and consensus ratings of safety, tolerability, and treatment-emergent switch risk. New to these guidelines, hierarchical rankings were created for first and second- line treatments recommended for acute mania, acute depression, and maintenance treatment in bipolar I disorder. Created by considering the impact of each treatment across all phases of illness, this hierarchy will further assist clinicians in making evidence-based treatment decisions. Lithium, quetiapine, divalproex, asenapine, aripiprazole, paliperidone, risperidone, and cariprazine alone or in combination are recommended as first-line treatments for acute mania. First-line options for bipolar I depression include quetiapine, lurasidone plus lithium or divalproex, lithium, lamotrigine, lurasidone, or adjunctive lamotrigine. While medications that have been shown to be effective for the acute phase should generally be continued for the maintenance phase in bipolar I disorder, there are some exceptions (such as with antidepressants); and available data suggest that lithium, quetiapine, divalproex, lamotrigine, asenapine, and aripiprazole monotherapy or combination treatments should be considered first-line for those initiating or switching treatment during the maintenance phase. In addition to addressing issues in bipolar I disorder, these guidelines also provide an overview of, and recommendations for, clinical management of bipolar II disorder, as well as advice on specific populations, such as women at various stages of the reproductive cycle, children and adolescents, and older adults. There are also discussions on the impact of specific psychiatric and medical comorbidities such as substance use, anxiety, and metabolic disorders. Finally, an overview of issues related to safety and monitoring is provided. The CANMAT and ISBD groups hope that these guidelines become a valuable tool for practitioners across the globe.
Bibliographical noteFunding Information:
Dr. Beny Lafer is supported by Brazilian Federal research grants and scholarships from CNPq and CAPES and a grant from the Brain & Behavior Research Foundation (NARSAD); Dr. Raymond Lam has received honoraria for ad hoc speaking or advising/consulting, or received research funds, from: Akili, Asia-Pacific Economic Cooperation, AstraZeneca, BC Leading Edge Foundation, Brain Canada, Bristol Myers Squibb, Canadian Institutes of Health Research, Canadian Depression Research and Intervention Network, Canadian Network for Mood and Anxiety Treatments, Canadian Psychiatric Association, Janssen, Lundbeck, Lundbeck Institute, Medscape, Pfizer, St. Jude Medical, Takeda, University Health Network Foundation, Vancouver Coastal Health Research Institute, and VGH Foundation; Dr. Glenda MacQueen has received honoraria for speaking or consulting from: AstraZeneca, Canadian Network for Mood and Anxiety Treatments, Canadian Psychiatric Association, Janssen, Lundbeck, Pfizer, Allergen, Sunovion; Dr. Gin Malhi has received grant or research support from National Health and Medical Research Council, Australian Rotary Health, NSW Health, Ramsay Health, American Foundation for Suicide Prevention, Ramsay Research and Teaching Fund, Elsevier, AstraZeneca and Servier; has been a speaker for AstraZeneca, Janssen-Cilag, Lundbeck, and Servier; and has been a consultant for AstraZeneca, Janssen Cilag, Lundbeck and Servier; Dr. Roger McIntyre has received research or grant support from Allergen Lundbeck, Purdue, Shire, Stanley Medical Research Institute, fees for speaking/consultation fromShire, Purdue, Otsuka, Janssen-Ortho, Lundbeck, Pfizer, Neurocrine, Neuralstem, Sunovion, Takeda, Allergan; Dr. Diane McIntosh has received honoraria for speaking or consulting for Janssen, Shire, Purdue, Lundbeck, BMS, Sunovion, Pfizer, Otsuka, Allergan, Valeant; Dr. Roumen Milev has received grant support from, participated on scientific advisory boards for or served on speakers bureaus of Lundbeck, Janssen, Pfizer, Forum, CIHR, Ontario Brain Institute, OMHF, Otsuka, Sunovion and Bristol Meyers Squibb; Dr. Claire O’Donovan has no conflict of interest; Dr. Sagar Parikh has received honoraria for consulting from Assurex and Takeda, honoraria for speaking from CANMAT, research grants from Assurex, Takeda, the Ontario Brain Institute, the Canadian Institutes for Health Research, the Ethel and James Flinn Foundation, and has shares in Mensante; Dr. Robert Post has spoken for AstraZeneca, Validus, Sunovion, Pamlabs, and Tekada; Dr. Arun Ravindran has received grant and research support from AstraZeneca, Bristol-Myers Squibb, Cephalon, Eli Lilly, GlaxoSmithKline, Janssen-Ortho, Lundbeck, Pfizer, Roche, Servier and Wyeth. Current industry grant awards: Janssen-Ortho. Dr Ravindran has also served as a consultant for some of the above institutions and on their Advisory Boards. He has also participated in CME programs sponsored by these and other pharmaceutical companies, such as Sunovion. He also holds or have held peer-reviewed funding from Canadian Institutes of Health Research, Grand Challenges Canada, Ontario Brain Institute, Ontario Mental Health Foundation, Canadian Foundation for Innovation and Ministry of Economic Development and Innovation, and National Institutes of Mental Health; Dr. Rej has received research support from Satellite Healthcare (US dialysis company). Otherwise, Dr. Soham Rej has received research support from the Canadian Institutes for Health Research (CIHR), Fonds de Recherche Quebec Sante (FRQS), Ontario Mental Health Foundation, Kidney Foundation of Canada, Physicians Services Incorporated Foundation, Mind and Life Institute, Brain Canada, Lady Davis Institute, McGill University, and Charitable donations to the Jewish General Hospital Division of Geriatric Psychiatry; Dr. Ayal Schaffer has received honoraria or other fees from Allergan, Asofarma, Lundbeck, and Sunovion; received research support from Ontario Mental Health Foundation; Canadian Institute of Health Research; American Foundation for Suicide Prevention; Ontario Ministry of Health and Long-Term Care (IMPACT Award); Dr. Verinder Sharma has received grant support from, participated on scientific advisory boards for, or served on speakers bureaus of Assurex, Genome Canada, Neurocrine Biosciences, Sage Therapeutics, Stanley Medical Research Institute, and Sunovion Pharmaceuticals; Dr. Trisha Suppes in the past 36 months has reported grants from National Institute of Mental Health, Sunovion Pharamaceuticals, Elan Pharma International Limited, VA Cooperative Studies Program, Pathway Genomics, Stanley Medical Research Institute, National Institute of Health, Palo Alto Health Sciences, and National Institute on Drug Abuse; consulting fees from A/S H. Lundbeck, Sunovion, and Merck & Co; honoraria from Medscape Education, Global Medical Education, and CMEology; royalties from Jones and Bartlett and UpToDate; and travel reimbursement from A/S H. Lundbeck, Sunovion Pharmaceuticals, Inc., Global Medication Education, CMEology, and Merck & Co.; Dr. Gustavo Vazquez has no conflict of interest; Dr. Eduard Vieta has received grants and served as consultant, advisor or CME speaker for the following entities: AB-Biotics, Allergan, Angelini, AstraZeneca, Bristol-Myers Squibb, Dainippon Sumitomo Pharma, Farmindustria, Ferrer, Forest Research Institute, Gedeon Richter, Glaxo-Smith-Kline, Janssen, Lundbeck, Otsuka, Pfizer, Roche, Sanofi-Aventis, Servier, Shire, Sunovion, Takeda, the Brain and Behaviour Foundation, the Spanish Ministry of Science and Innovation (CIBERSAM), the Seventh European Framework Programme (ENBREC), and the Stanley Medical Research Institute; Dr. Lakshmi Yatham has received research grants from or has been on speaker ⁄ advisory boards for Allergan, AstraZeneca, Alkermes, Bristol-Myers Squibb, Canadian Institutes of Health Research, Canadian Network for Mood and Anxiety Treatments, Dainippon Sumitomo Inc, Eli Lilly & Co., Forrest, GlaxoSmithKline, Janssen, Lundbeck, Michael Smith Foundation for Health Research, Novartis, Otsuka, Pfizer, Ranbaxy, Servier, Sunovion, the Stanley Foundation, and Valeant Pharmaceuticals.
Nova Scotia Health Research Foundation, and Stanley Medical Research Institute; Dr. Serge Beaulieu has received peer-reviewed research funding from Canadian Institutes of Health Research, Pfizer Research Award, NARSAD, and support for KT and research contracts from Astra-Zeneca, Bristol-Myers-Squibb, Lundbeck, Otsuka, Sunovion; been a consultant or part of an advisory board for Allergan, Astra Zeneca, BMS, Forest Laboratories, Janssen-Ortho, Lundbeck, Merck, Otsuka, Pfizer, Sunovion; and part of the speaker bureau for Allergan, Astra Zeneca, BMS, Janssen-Ortho, Lundbeck, Otsuka, Pfizer, Purdue, Sunovion; Dr. Michael Berk has received grant/research Support from the NIH, Cooperative Research Centre, Simons Autism Foundation, Cancer Council of Victoria, Stanley Medical Research Foundation, MBF, NHMRC, Beyond Blue, Rotary Health, Geelong Medical Research Foundation, Bristol Myers Squibb, Eli Lilly, Glaxo SmithKline, Meat and Livestock Board, Organon, Novartis, Mayne Pharma, Servier, Woolworths, Avant and the Harry Windsor Foundation, has been a speaker for Astra Zeneca, Bristol Myers Squibb, Eli Lilly, Glaxo SmithKline, Janssen Cilag, Lundbeck, Merck, Pfizer, Sanofi Synthelabo, Servier, Solvay and Wyeth, and served as a consultant to Allergan, Astra Zeneca, Bioadvantex, Bionomics, Collaborative Medicinal Development, Eli Lilly, Grunbiotics, Glaxo SmithKline, Janssen Cilag, LivaNova, Lundbeck, Merck, Mylan, Otsuka, Pfizer and Servier. MB is supported by a NHMRC Senior Principal Research Fellowship 1059660; Dr. David Bond has served on advisory boards and/or received research support from Myriad Genetics; Dr. Joseph Calabrese has received grants and/or served as consultant, advisor or CME speaker for the following entities: Alkermes Inc., the Cleveland Foundation, Janssen Pharmaceuticals Inc., Lundbeck, the National Institute of Mental Health, Otsuka Pharmaceutical, Sumitomo Dainippon and Sunovion Pharmaceuticals Canada Inc.; Dr. Benicio Frey has served on advisory boards for Lundbeck, Pfizer, Sunovion and received research support from Pfizer; Dr. Benjamin Goldstein has received grant support from Brain Canada, CIHR, Heart and Stroke Foundation, Ontario Ministry of Research, Innovation, and Science, NIMH; Dr. Shigenobu Kanba has received research funding from Dainippon-Sumitomo Pharma, Jansen Pharma, Asteras Pharma, Nipponchemipha, Pfizer, Mochida Pharma, Esai, Tanabe-Mitsubishi Pharma, Meiji Seika Pharma, Yoshitomi Pharma, Shionogi Pharma, and Tanabe Mitsubishi. He has received honorarium from MSD, Asteras Pharma, Mochida Pharma, Esai, Takeda Pharma, Dainippon-Sumitomo Pharma, Otsuka Pharma, Taisho-Toyama Pharma, Jansen Pharma, Meiji Seika Pharma, Yoshitomi Pharma, Takeda Pharma, Nipponchemipha, Daiichi-Sankyo, Pfizer, Mochida Pharma, Shionogi Pharma, and Tanabe-Mitsubishi Pharma; Dr. Flavio Kapczinski has received grants/research support from AstraZeneca, Eli Lilly, Janssen-Cilag, Servier, NARSAD, and the Stanley Medical Research Institute; has been a member of the speakers’ boards of Astra Zeneca, Eli Lilly, Janssen and Servier; and has served as a consultant for Servier; Dr. Sidney Kennedy has received research funding or honoraria from the following sources: Abbott, Allergan, AstraZeneca, BMS, Brain Canada, Canadian Institutes for Health Research (CIHR), Janssen, Lundbeck, Lundbeck Institute, OMHF, Ontario Brain Institute, Ontario Research Fund(ORF), Otsuka, Pfizer, Servier, St. Jude Medical, Sunovion and Xian-Janssen; Dr. Jan Kozicky is an employee of Indivior Canada Ltd;
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