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GUIDELINE DEVELOPMENT PROCESS SCREENING/ASSESSMENT/DIAGNOSIS PHARMACOLOGIC RECOMMENDATIONS OTHER SOMATIC THERAPIES NONPHARMACOLOGIC RECOMMENDATIONS COMPARISON TO OTHER GUIDELINES DISCUSSION Article Information Clinical Points
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Consensus Statement January 13, 2025

Synopsis of the 2023 US Department of Veterans Affairs and US Department of Defense Clinical Practice Guideline for the Management of Bipolar Disorder

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J Clin Psychiatry 2025;86(1):24cs15546

Abstract

Objective: The US Department of Veterans Affairs (VA) and Department of Defense (DOD) Work Group revised the 2013 VA/DOD Clinical Practice Guideline (CPG) for the Management of Bipolar Disorder (BD). This paper reviews the 2023 CPG and its development process, including how recommendations were made for evidence-based treatment in BD.

Methods: Subject experts and key stakeholders developed 20 key questions and reviewed the published literature after a systematic search using the PICOTS (population, intervention, comparator, outcomes, timing of outcomes measurement, and setting) method. The evidence was then evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) method. Recommendations were based on quality and strength of evidence and informed by other factors, including feasibility, patient perspectives, and the unique needs of people with BD. Peer review by an external group of experts then resulted in completion of the CPG.

Recommendations: While the scope of the CPG is broad, this synopsis focuses on clinically relevant recommendations related to the identification and management of BD, including the acute and maintenance phases of illness.

J Clin Psychiatry 2025;86(1):24cs15546

Author affiliations are listed at the end of this article.

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  1. James SL, Abate D, Abate KH, et al. Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet. 2018;392(10159):1789–1858. PubMed
  2. Chan JKN, Tong CHY, Wong CSM, et al. Life expectancy and years of potential life lost in bipolar disorder: systematic review and meta-analysis - CORRIGENDUM. Br J Psychiatry. 2022;221(4):647–648. PubMed
  3. Williams MD, Shah ND, Wagie AE, et al. Direct costs of bipolar disorder versus other chronic conditions: an employer-based health plan analysis. Psychiatr Serv. 2011;62(9):1073–1078. PubMed CrossRef
  4. Cloutier M, Greene M, Guerin A, et al. The economic burden of bipolar I disorder in the United States in 2015. J Affect Disord. 2018;226:45–51. PubMed CrossRef
  5. Military Health System. Defense Medical Epidemiology Database 2022. Accessed December 17, 2024. https://www.health.mil/Military-Health-Topics/Health-Readiness/AFHSD/Functional-Information-Technology-Support/DefenseMedical-Epidemiology-Database
  6. VA Serious Mental Illness Treatment Resource and Evaluation Center (SMITREC). 2022.
  7. Ilgen MA, Bohnert AS, Ignacio RV, et al. Psychiatric diagnoses and risk of suicide in veterans. Arch Gen Psychiatry. 2010;67(11):1152–1158. CrossRef
  8. Graham R, Mancher M, Miller Wolman D, et al, eds. Clinical Practice Guidelines We Can Trust. National Academies Press; 2011.
  9. Andrews JC, Schunemann HJ, Oxman AD, et al. GRADE guidelines: 15. Going from evidence to recommendation-determinants of a recommendation’s direction and strength. J Clin Epidemiol. 2013;66(7):726–735. PubMed CrossRef
  10. Andrews J, Guyatt G, Oxman AD, et al. GRADE guidelines: 14. Going from evidence to recommendations: the significance and presentation of recommendations. J Clin Epidemiol. 2013;66(7):719–725. PubMed CrossRef
  11. Atkins D, Best D, Briss PA, et al. Grading quality of evidence and strength of recommendations. BMJ. 2004;328(7454):1490. PubMed
  12. Clemente AS, Diniz BS, Nicolato R, et al. Bipolar disorder prevalence: a systematic review and meta-analysis of the literature. Braz J Psychiatry. 2015;37(2):155–161. PubMed CrossRef
  13. Merikangas KR, Jin R, He JP, et al. Prevalence and correlates of bipolar spectrum disorder in the world mental health survey initiative. Arch Gen Psychiatry. 2011;68(3):241–251. PubMed CrossRef
  14. Carvalho AF, Takwoingi Y, Sales PM, et al. Screening for bipolar spectrum disorders: a comprehensive meta-analysis of accuracy studies. J Affect Disord. 2015;172:337–346. PubMed CrossRef
  15. Wang YY, Xu DD, Liu R, et al. Comparison of the screening ability between the 32- item Hypomania Checklist (HCL-32) and the Mood Disorder Questionnaire (MDQ) for bipolar disorder: a meta-analysis and systematic review. Psychiatry Res. 2019;273:461–466. PubMed CrossRef
  16. Cerimele JM, Chwastiak LA, DODson S, et al. The prevalence of bipolar disorder in general primary care samples: a systematic review. Gen Hosp Psychiatry. 2014;36(1):19–25. PubMed CrossRef
  17. Youngstrom EA, Egerton GA, Genzlinger J, et al. Improving the global identification of bipolar spectrum disorders: meta-analysis of the diagnostic accuracy of checklists. Psychol Bull. 2018;144(3):315–342. PubMed CrossRef
  18. Cerimele JM, Goldberg SB, Miller CJ, et al. Systematic review of symptom assessment measures for use in measurement-based care of bipolar disorders. Psychiatr Serv. 2019;70(5):396–408. PubMed CrossRef
  19. Kishi T, Ikuta T, Matsuda Y, et al. Pharmacological treatment for bipolar mania: a systematic review and network meta-analysis of double-blind randomized controlled trials. Mol Psychiatry. 2022;27(2):1136–1144. CrossRef
  20. Kishi T, Ikuta T, Matsuda Y, et al. Mood stabilizers and/or antipsychotics for bipolar disorder in the maintenance phase: a systematic review and network meta-analysis of randomized controlled trials. Mol Psychiatry. 2021;26(8):4146–4157. CrossRef
  21. Ogawa Y, Tajika A, Takeshima N, et al. Mood stabilizers and antipsychotics for acute mania: a systematic review and meta-analysis of combination/augmentation therapy versus monotherapy. CNS Drugs. 2014;28(11):989–1003. CrossRef
  22. Nestsiarovich A, Gaudiot CES, Baldessarini RJ, et al. Preventing new episodes of bipolar disorder in adults: systematic review and meta-analysis of randomized controlled trials. Eur Neuropsychopharmacol. 2022;54:75–89. PubMed CrossRef
  23. Kishi T, Matsuda Y, Sakuma K, et al. Recurrence rates in stable bipolar disorder patients after drug discontinuation v. drug maintenance: a systematic review and meta-analysis. Psychol Med. 2021;51(15):2721–2729. PubMed CrossRef
  24. Kishi T, Sakuma K, Okuya M, et al. Effects of a conventional mood stabilizer alone or in combination with second-generation antipsychotics on recurrence rate and discontinuation rate in bipolar I disorder in the maintenance phase: a systematic review and meta-analysis of randomized, placebo-controlled trials. Bipolar Disord. 2021;23(8):789–800.
  25. Bahji A, Ermacora D, Stephenson C, et al. Comparative efficacy and tolerability of pharmacological treatments for the treatment of acute bipolar depression: a systematic review and network meta-analysis. J Affect Disord. 2020;269:154–184. CrossRef
  26. Wang H, Xiao L, Wang HL, et al. Efficacy and safety of lurasidone versus placebo as adjunctive to mood stabilizers in bipolar I depression: a meta-analysis. J Affect Disord. 2020;264:227–233. PubMed CrossRef
  27. Rajagopalan K, Bacci ED, Wyrwich KW, et al. The direct and indirect effects of lurasidone monotherapy on functional improvement among patients with bipolar depression: results from a randomized placebo-controlled trial. Int J Bipolar Disord. 2016;4(1):7. PubMed CrossRef
  28. Calabrese JR, Durgam S, Satlin A, et al. Efficacy and safety of lumateperone for major depressive episodes associated with bipolar I or bipolar II disorder: a phase 3 randomized placebo-controlled trial. Am J Psychiatry. 2021;178(12):1098–1106. CrossRef
  29. Kadakia A, Dembek C, Heller V, et al. Efficacy and tolerability of atypical antipsychotics for acute bipolar depression: a network meta-analysis. BMC Psychiatry. 2021;21(1):249. PubMed CrossRef
  30. Bahji A, Ermacora D, Stephenson C, et al. Comparative efficacy and tolerability of adjunctive pharmacotherapies for acute bipolar depression: a systematic review and network meta-analysis. Can J Psychiatry. 2021;66(3):274–288. PubMed CrossRef
  31. McGirr A, Vöhringer PA, Ghaemi SN, et al. Safety and efficacy of adjunctive second-generation antidepressant therapy with a mood stabiliser or an atypical antipsychotic in acute bipolar depression: a systematic review and meta-analysis of randomised placebo-controlled trials. Lancet Psychiatry. 2016;3(12):1138–1146. CrossRef
  32. Tohen M, Vieta E, Calabrese J, et al. Efficacy of olanzapine and olanzapine fluoxetine combination in the treatment of bipolar I depression. Arch Gen Psychiatry. 2003;60(11):1079–1088. CrossRef
  33. Dean RL, Marquardt T, Hurducas C, et al. Ketamine and other glutamate receptor modulators for depression in adults with bipolar disorder. Cochrane Database Syst Rev. 2021;10(10):Cd011611. PubMed CrossRef
  34. Diazgranados N, Ibrahim L, Brutsche NE, et al. A randomized add-on trial of an N-methyl-D-aspartate antagonist in treatment-resistant bipolar depression. Arch Gen Psychiatry. 2010;67(8):793–802. CrossRef
  35. Zarate CA Jr, Brutsche NE, Ibrahim L, et al. Replication of ketamine’s antidepressant efficacy in bipolar depression: a randomized controlled add-on trial. Biol Psychiatry. 2012;71(11):939–946. PubMed CrossRef
  36. Grunebaum MF, Ellis SP, Keilp JG, et al. Ketamine versus midazolam in bipolar depression with suicidal thoughts: a pilot midazolam-controlled randomized clinical trial. Bipolar Disord. 2017;19(3):176–183. PubMed CrossRef
  37. Bahji A, Vazquez GH, Zarate CA Jr. Comparative efficacy of racemic ketamine and esketamine for depression: a systematic review and meta-analysis. J Affect Disord. 2021;278:542–555. CrossRef
  38. Thase ME, Macfadden W, Weisler RH, et al. Efficacy of quetiapine monotherapy in bipolar I and II depression: a double-blind, placebo-controlled study (the BOLDER II study). J Clin Psychopharmacol. 2006;26(6):600–609.
  39. Suttajit S, Srisurapanont M, Maneeton N, et al. Quetiapine for acute bipolar depression: a systematic review and meta-analysis. Drug Des Devel Ther. 2014;8:827–838. CrossRef
  40. Weisler RH, Nolen WA, Neijber A, et al. Continuation of quetiapine versus switching to placebo or lithium for maintenance treatment of bipolar I disorder (Trial 144: a randomized controlled study). J Clin Psychiatry. 2011;72(11):1452–1464. PubMed CrossRef
  41. FDA. Depakote (Divalproex Sodium) Delayed-Release tablets, for oral use initial U.S. approval: 1983; 2020. Accessed September 4, 2024. https://www.accessdata.fda.gov/drugsatfda_docs/label/2020/018723s063lbl.pdf
  42. Zhang J, Wang G, Yang X, et al. Efficacy and safety of electroconvulsive therapy plus medication versus medication alone in acute mania: a meta-analysis of randomized controlled trials. Psychiatry Res. 2021;302:114019. CrossRef
  43. Lam RW, Teng MY, Jung YE, et al. Light therapy for patients with bipolar depression: systematic review and meta-analysis of randomized controlled trials. Can J Psychiatry. 2020;65(5):290–300. PubMed CrossRef
  44. Miklowitz DJ, Efthimiou O, Furukawa TA, et al. Adjunctive psychotherapy for bipolar disorder: a systematic review and component network meta-analysis. JAMA Psychiatry. 2021;78(2):141–150. PubMed CrossRef
  45. Killackey E, Allott K, Jackson HJ, et al. Individual placement and support for vocational recovery in first-episode psychosis: randomised controlled trial. Br J Psychiatry. 2019;214(2):76–82. PubMed CrossRef
  46. Christensen TN, Wallstrøm IG, Stenager E, et al. Effects of individual placement and support supplemented with cognitive remediation and work-focused social skills training for people with severe mental illness: a randomized clinical trial. JAMA Psychiatry. 2019;76(12):1232–1240. PubMed CrossRef
  47. Perlick DA, Jackson C, Grier S, et al. Randomized trial comparing caregiver-only family-focused treatment to standard health education on the 6-month outcome of bipolar disorder. Bipolar Disord. 2018;20(7):622–633. PubMed CrossRef
  48. Madigan K, Egan P, Brennan D, et al. A randomised controlled trial of carer focussed multi-family group psychoeducation in bipolar disorder. Eur Psychiatry. 2012;27(4):281–284. PubMed CrossRef
  49. Kilbourne AM, Goodrich DE, Lai Z, et al. Randomized controlled trial to assess reduction of cardiovascular disease risk in patients with bipolar disorder: the Self Management Addressing Heart Risk Trial (SMAHRT). J Clin Psychiatry. 2013;74(7):e655–e662. PubMed CrossRef
  50. van der Voort TY, van Meijel B, Goossens PJ, et al. Collaborative care for patients with bipolar disorder: randomised controlled trial. Br J Psychiatry. 2015;206(5):393–400. CrossRef
  51. Salazar-Ospina A, Amariles P, Hincapié-García JA, et al. Effectiveness of the dader method for pharmaceutical care on patients with bipolar I disorder: results from the EMDADER-TAB study. J Manag Care Spec Pharm. 2017;23(1):74–84. PubMed CrossRef
  52. Kilbourne AM, Goodrich DE, Lai Z, et al. Life Goals Collaborative Care for patients with bipolar disorder and cardiovascular disease risk. Psychiatr Serv. 2012;63(12):1234–1238. PubMed CrossRef
  53. Hawke LD, Parikh SV, Michalak EE. Stigma and bipolar disorder: a review of the literature. J Affect Disord. 2013;150(2):181–191. PubMed CrossRef
  54. Latalova K, Ociskova M, Prasko J, et al. Self-stigmatization in patients with bipolar disorder. Neuro Endocrinol Lett. 2013;34(4):265–272.
  55. SAMHSA. Recovery and recovery support. 2022. Accessed December 17, 2024. https://www.samhsa.gov/find-help/recovery
  56. Yatham LN, Kennedy SH, Parikh SV, et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) 2018 guidelines for the management of patients with bipolar disorder. Bipolar Disord. 2018;20(2):97–170. CrossRef
  57. Bipolar Disorder: The NICE Guideline on the Assessment and Management of Bipolar Disorder in Adults, Children and Young People in Primary and Secondary Care. National Institute for Health and Care Excellence: Clinical Guidelines; 2014.
  58. Hirschfeld RM, Cass AR, Holt DC, et al. Screening for bipolar disorder in patients treated for depression in a family medicine clinic. J Am Board Fam Pract. 2005;18(4):233–239. CrossRef
  59. Marzani G, Price Neff A. Bipolar disorders: evaluation and treatment. Am Fam Physician. 2021;103(4):227–239.
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