Bipolar disorder: assessment and management

Evidence

We found 32 studies in a search for randomised controlled trials and systematic reviews published between 1 January 2014 and 5 April 2017.

We also checked for relevant ongoing research, which will be evaluated again at the next surveillance review of the guideline.

See appendix A: summary of evidence from surveillance for details of all evidence considered, and references.

Views of topic experts

We considered the views of topic experts, including those who helped to develop the guideline and other correspondence we have received since the publication of the guideline.

Views of stakeholders

Stakeholders commented on the decision not to update the guideline. Overall, 6 stakeholders commented. See appendix B for stakeholders' comments and our responses.

Of the stakeholders who commented on the proposal not to update the guideline: 3 agreed and 3 disagreed with the decision. One stakeholder who agreed with the decision commented that it is worth deferring the update until results of ongoing studies are known. Stakeholders who disagreed suggested that the evidence on psychological therapies requires a review. The suggestions include consideration of cognitive analytic therapy to be included in the recommendations and reconsideration of the recommendations to offer cognitive behavioural therapy (CBT) and couples therapy as treatment options. However, another stakeholder commented that the use of bipolar specialist psychological therapies is not realistic and is costly. They suggest that generic CBT is appropriate and reasonable for this population. Evidence on psychological therapies was reviewed during the surveillance review and determined that inconsistencies in results were too great to impact current recommendations.

Two stakeholders commented on the use of pharmacological interventions for bipolar disorder. It was stated that aripiprazole is now generic and could be cost effective as a treatment option for mania. At the surveillance review, the evidence identified for aripiprazole provided inconclusive results for its effectiveness in an adult population with bipolar disorder. Aripiprazole is recommended for children and young people to treat mania and is included in NICE's technology appraisal guidance on aripiprazole for moderate to severe manic episodes in adolescents. However, without further robust evidence in adults, it is unlikely to impact recommendations at this time.

One stakeholder commented that lamotrigine is not mentioned in the recommendations though it has a license for the long-term treatment of bipolar disorder. Although lamotrigine is now licensed for use in long-term treatment, no evidence was found at all during the surveillance review for its use in a bipolar disorder population. Until evidence on its effectiveness is available, it is unlikely to impact recommendations at this time.

It was also stated that the recommendations on the use of lithium be reviewed. The suggestion is that if lithium is ineffective then it should be withdrawn. Also, if it has been partially effective then it should be used in combination with another maintenance agent as there is no randomised controlled trial evidence to support the addition of valproate. During the development of the guideline, the guideline committee considered lithium as the preferred choice of drug as it has a better profile than valproate in the long-term management of bipolar disorder. At the time, it was determined that individual medications can be used with clinical judgement and in some clinical circumstances other medications might be preferable to lithium. The guideline committee acknowledged the poor evidence base and suggested that prescribers use their expert judgement when considering treatment options.

A further stakeholder comment suggests the use of routine HIV testing due to the presence of mania and psychosis as features of HIV cognitive impairment. This area is not covered in NICE guideline CG185 and no evidence to support this view was identified during the surveillance review.

See ensuring that published guidelines are current and accurate in developing NICE guidelines: the manual for more details on our consultation processes.

NICE Surveillance programme project team

Kay Nolan
Associate Director

Jeremy Wight
Consultant Clinical Adviser

Emma McFarlane
Technical Adviser

Omar Moreea
Technical Analyst

The NICE project team would like to thank the topic experts who participated in the surveillance process.

ISBN: 978-1-4731-2470-7