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The clinical management of bipolar disorder complexity using a stratified model

Authors

  • Gin S Malhi,

    1. CADE Clinic, Department of Psychiatry, Royal North Shore Hospital
    2. Discipline of Psychiatry, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
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  • Danielle M Bargh,

    1. CADE Clinic, Department of Psychiatry, Royal North Shore Hospital
    2. Discipline of Psychiatry, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
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  • Emma Cashman,

    1. CADE Clinic, Department of Psychiatry, Royal North Shore Hospital
    2. Discipline of Psychiatry, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
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  • Mark A Frye,

    1. Department of Psychiatry, Mayo Mood Clinic and Research Program, Mayo College of Medicine, Rochester, MN
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  • Michael Gitlin

    1. Department of Psychiatry, Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, USA
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Corresponding author:
Professor Gin S. Malhi
Department of Psychiatry
University of Sydney
CADE Clinic
Level 5, Building 36
Royal North Shore Hospital
St. Leonards, NSW 2065, Australia
Fax: +61 2 9926-7730
E-mail: gin.malhi@sydney.edu.au

Abstract

Malhi GS, Bargh DM, Cashman E, Frye MA, Gitlin M. The clinical management of bipolar disorder complexity using a stratified model. Bipolar Disord 2012: 14 (Suppl. 2): 66–89. © 2012 The Authors. Journal compilation © 2012 John Wiley & Sons A/S.

Objective:  To provide practical and clinically meaningful treatment recommendations that amalgamate clinical and research considerations for several common, and as yet understudied, bipolar disorder complex presentations, within the framework of a proposed stratified model.

Methods:  A comprehensive search of the literature was undertaken using electronic database search engines (Medline, PubMed, Web of Science) using key words (e.g., bipolar disorder, anxiety, rapid cycling, and subsyndromal). All relevant randomised controlled trials were examined, in addition to review papers, meta-analyses, and book chapters known to the authors. The findings formed the basis of the treatment recommendations within this paper.

Results:  In light of the many broad presentations of bipolar disorder, a stratified model of bipolar disorder complexity was developed to facilitate consideration of the myriad of complexities that can occur during the longitudinal course of illness and the appropriate selection of treatment. Evidence-based treatment recommendations are provided for the following bipolar disorder presentations: bipolar II disorder, subsyndromal symptoms, mixed states, rapid cycling, comorbid anxiety, comorbid substance abuse, and for the following special populations: young, elderly, and bipolar disorder around the time of pregnancy and birth. In addition, some key strategies for countering treatment non-response and alternative medication recommendations are provided.

Conclusions:  Treatment recommendations for the more challenging presentations of bipolar disorder have historically received less attention, despite their prevalence. This review acknowledges the weaknesses in the current evidence base on which treatment recommendations are generally formulated, and additionally emphasises the need for high-quality research in this area. The stratified model provides a means for conceptualizing the complexity of many bipolar disorder presentations and considering their management.

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