What Constitutes Evidence-Based Pharmacotherapy for Bipolar Disorder? Part 2: Complex Presentations and Clinical Context

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Part 1 of this ASCP CORNER examinedgeneral principles of evidence-based medicine(EBM) regarding first-line pharmacotherapiesacross illness phases of bipolardisorder.¹ We shall now consider evidencebasedpharmacotherapy for clinical presentationsthat fall outside the usual andcustomary realm—for example, due toatypical (e.g., “not otherwise specified”[NOS]) or mixed affective features, coursespecifiers (e.g., rapid cycling), true comorbidities,or frank treatment resistance.Since many patients with bipolar disorderare neither usual nor customary, those with”non-prototypical” features may well comprisethe majority of treatment-seekingpatients.

EBM discourages sweeping overgeneralizations(e.g., “Aminoglycosides aregood antibiotics”), instead linking drugutility with context (e.g., “Aminoglycosidesare good antibiotics for gram-negative infectionsin renally intact patients”); hence,distinct clinical contexts (e.g., “Quetiapinetreats depression in bipolar II patients withrapid cycling”) may offer more useful waysof thinking than unspecified clinical contexts(e.g., “Is quetiapine useful for bipolardisorder?”).’ ‹’ ‹