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Bipolar disorder: Clinical recommendations

Table 3.2: Levels of evidence and clinical recommendations for treatment of bipolar disorder


treatment acute mania level of evidence (recommendation) acute depression level of evidence (recommendation)

prophylaxis level of evidence

Lithium I (A for mania, B for mixed) I (A) I (A)
Antiepileptic agents



I (A for mania

and mixed states)
III (B) I (A)
Carbamazepine I (C) II (C) II (C)
Lamotrigine III (D) I (A) I (A)
Gabapentin III (D) III (D) III (D)
Topiramate III (D) III (D) III (D)
Oxcarbazepine I (C) III (D) III (D)
Novel antipsychotic drugs      
Olanzapine I (A) I (B) I (A)
Risperidone I (A) III (C) II (B)
Quetiapine I (A) I (A) III (C)
Ziprasidone I (A) III (D) III (D)
Aripiprazole I (A) III (D/E) I (A)
Novel antidepressants      
SSRIs, SNRIs, NaSSAs* (E) I (B) III (D)


* SSRI = selective serotonin reuptake inhibitor; SNRI = serotonin noradrenaline reuptake inhibitor; NaSSA = noradrenaline specific serotinin antagonist

Mixed state is the simultaneous presence of mania and depression. A – Recommended first-line treatment

B – Recommended second-line treatment


C – Recommended third-line treatment


D – No recommendation or proscription


E – Not recommended


Reprinted with permission from McIntyre et al., 2004. Copyright The College of Family

Physicians of Canada, 2004.