Objectives. These guidelines are based on a fi rst edition that was published in 2004, and have been edited and updated with the available scientifi c evidence up to October 2012. Their purpose is to supply a systematic overview of all scientifi c evidence pertaining to the long-term treatment of bipolar disorder in adults. Methods . Material used for these guidelines are based on a systematic literature search using various data bases. Their scientifi c rigor was categorised into six levels of evidence (A – F) and different grades of recommendation to ensure practicability were assigned. Results . Maintenance trial designs are complex and changed fundamentally over time; thus, it is not possible to give an overall recommendation for long-term treatment. Different scenarios have to be examined separately: Prevention of mania, depression, or an episode of any polarity, both in acute responders and in patients treated de novo . Treatment might differ in Bipolar II patients or Rapid cyclers, as well as in special subpopulations. We identifi ed several medications preventive against new manic episodes, whereas the current state of research into the prevention of new depressive episodes is less satisfactory. Lithium continues to be the substance with the broadest base of evidence across treatment scenarios. Conclusions . Although major advances have been made since the fi rst edition of this guideline in 2004, there are still areas of uncertainty, especially the prevention of depressive episodes and optimal long-term treatment of Bipolar II patients.

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The World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for the biological treatment of bipolar disorders: update 2012 on the long-term treatment of bipolar disorder.

Depressive disorders and suicide: Epidemiology, risk factors, and burden.

Mixed states in DSM-5: Implications for clinical care, education, and research

The DSM system has never acknowledged a central position for mixed states; thus, mixed depressions have been almost completely neglected for decades. Now, DSM-5 is proposing diagnostic criteria for depression with mixed features that will lead to more misdiagnosis and inadequate treatment of this syndrome. Different criteria, based on empirically stronger evidence than exists for the DSM-5 criteria, should be adopted.

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Mixed features of depression: why DSM-5 is wrong (and so was DSM-IV)

Background Major depression is the leading cause of disability worldwide, and among the 10 most frequent indications for using alternative medicine therapies, especially dietary supplements. Objective To assess the evidence evaluating vitamin B-6 supplementation as treatment for depression. Methods Medline, Psychinfo, AMED, and Cochrane Controlled Trials Register were searched from database inception through September 2001. All randomized controlled trials, controlled clinical trials, intervention studies, case-control studies, reviews, and case reports examining the evidence behind vitamin B-6 in depression among humans were selected. No limits were placed for demographics or co-morbidities. Only English language papers were abstracted and assessed for trial quality. Two abstractors independently evaluated each study, then reconciled findings. As data were available, between group treatment effect size was noted or, as needed, calculated. When studies reported outcome effects using multiple measures, data were abstracted to permit the greatest possible comparisons among papers. Results Ten articles met inclusion criteria; three reviews, one case report, five RCTs, and one intervention study. There was no common outcome measure among all studies, eliminating opportunity for direct comparison of effect sizes. As an alternate means of comparison, effects were plotted as they related to the null hypothesis. Conclusion Viewed as a whole, meaningful treatment effect of vitamin B-6 for depression in general was not apparent. However, examination of papers addressing depression in pre-menopausal women only, reveals a consistent message about the value of using vitamin B-6 supplementation. Further study of vitamin B-6 as independent and adjuvant therapy for hormone related depression in women is indicated.

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J.R. Smythies

Papers

Chapter III – Mania and depression