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 examined general principles of evidence-based medicine (EBM) regarding first-line pharmacotherapies across illness phases of bipolar disorder.1 We shall now consider evidencebased pharmacotherapy for clinical presentations that fall outside the usual and customary realm—for example, due to atypical (e.g., “not otherwise specified” [NOS]) or mixed affective features, course specifiers (e.g., rapid cycling), true comorbidities, or frank treatment resistance. Since many patients with bipolar disorder are neither usual nor customary, those with “non-prototypical” features may well comprise the majority of treatment-seeking patients.

EBM discourages sweeping overgeneralizations (e.g., “Aminoglycosides are good antibiotics”), instead linking drug utility with context (e.g., “Aminoglycosides are good antibiotics for gram-negative infections in renally intact patients”); hence, distinct clinical contexts (e.g., “Quetiapine treats depression in bipolar II patients with rapid cycling”) may offer more useful ways of thinking than unspecified clinical contexts (e.g., “Is quetiapine useful for bipolar disorder?”).​​

J Clin Psychiatry 2008;69(3):495-496