Canadian mood and and anxiety network

The following is a summary of the stepwise selection of choices for prophylaxis in bipolar affective disorder. The guidelines recommend to review general principles and assess medication status before starting treatment.

  • Review general principles and assess medication status.

  • Initiate therapy using one of the first-line agents.

  • Recommend an alternate first-line agents OR an add-on agent.

  • Recommend an add-on treatment option or or switch to one of the second‐line agent.

  • Recommend an add-on treatment option or or switch to one of the third‐line agents.

CANMAT Guidelines on Bipolar Prophylaxis

First-line Choices

The following choices are the first-line choices supported by  best evidence, administrative data, and experience:

  1. Lithium
  2. Quetiapine
  3. Divalproex, and 
  4. Lamotrigine

Other first-line agents include asenapine, aripiprazole oral, or once monthly. 

Combination therapies

Combination therapies considered the first‐line include 

  • quetiapine adjunctive therapy with lithium/divalproex and 
  • aripiprazole plus lithium/divalproex.


Second-line Choices

The following is a list of second-line choices with reason in the bracket, for why they are a second-line choice. 

  1. Olanzapine (safety issues-metabolic syndrome), 
  2. Risperidone long-acting injectable (no clear efficacy preventing depression), 
  3. Carbamazepine (no placebo control trials, only comparator trials), 
  4. Paliperidone (less effective than olanzapine)


Third-line Choices

Aripiprazole + lamotrigine, Clozapine (adj), Gabapentin (adj), Olanzapine + fluoxetine


Not recommended

Perphenazine, Tricyclic antidepressants

References

1.    Yatham LN, Kennedy SH, Parikh S V., 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. doi:10.1111/bdi.12609


Bipolar Affective Disorder

A virtual training module for psychiatry trainees.

There are three ways you pick up on clinical skills: (1) Reading (2) Observing experienced clinicians. (3) Applying your knowledge to practice. In this module, you will apply your knowledge to common, serious, and tricky scenarios.
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Authors

Old-age Psychiatrist

Raja Adnan Ahmad

MBBS, MRCPsych, MSc Medical Education.

Consultant Psychiatrist (SR)

Waleed Ahmad

Faculty, Department of Psychiatry, Peshawar Medical College, MBBS, FCPS. I study and treat patients with OCD, only.

Consultant Psychiatrist (SR)

Saqib Siddique

Assistant Professor of Psychiatry, PIMC, Peshawar. MBBS (KMC), DCP (IRE), FCPS (PAK), Certified Cognitive Therapist (KMU).