Avis critique sur la place du lithium dans les recommandations professionnelles sur la prise en charge du trouble bipolaire

Abstract

ObjectivesIn the last few decades, from the discovery of lithium, an increasing number of drugs have been approved for the treatment of bipolar disorders. Guidelines have been established to help clinicians make a relevant choice of medication in specific clinical circumstances. The aim of this article is to review the place of lithium in the recent guidelines for the treatment of bipolar disorder. Materials and methodsWe reviewed the recently published guidelines in English and in French for the management of bipolar disorder. Electronic library and Web-based searches were performed using recognized tools (MEDLINE, PubMED and EMBASE) to identify guidelines that have been published since 2006. In addition, other sources of information known to us, such as national agency reports, were searched. ResultsSince 2006, seven sets of guidelines have been established or updated by official scientific societies. The different guidelines are in agreement on the choice of lithium to be used as a first-line treatment for mania. The efficacy of lithium in combination with second-generation antipsychotic in the management of manic episodes has made these associations first-line choices in some guidelines. However, choosing a combination from the outset for the management of mania will depend on whether the Task Force that developed the guidelines gives priority to efficacy or tolerance and not on the guidelines methodology, which is used. For the treatment of bipolar depressive episode, the only drug recommended in monotherapy as first-line treatment by all guidelines is quetiapine. The place of lithium in this indication is controversial and only some guidelines recommend lithium in monotherapy as first-line strategy. The recommendation grade of lithium depends on how the results of the studies are interpreted by the Task Force elaborating the guideline. Guidelines disagree on the first-line treatment choice in mixed state. Some guidelines make no distinction between treatments of classic mania and that of mixed state. The other guidelines consider lithium to be less efficacious in this indication. For the long-term treatment, all guidelines take into consideration the predominant mood polarity of the patient. Lithium is considered to have an important role in preventive strategies for bipolar disorder whatever the predominant mood polarity. However, it is perceived as a more effective treatment in the prevention of manic episodes than depressive episodes. ConclusionsLithium remains a gold standard treatment in the recently published practice guidelines. The main differences between the guidelines on its use are related to methodological discrepancies and interpretation of the scientific data by the Task Force that developed the guidelines.