Table 5.

Recommended therapies for diverse subcategories of bipolar disorder according to CANMAT 2018 and CANMAT 2021

Type of episode	First-line treatment	Next-step intervention	Later intervention
Acute mania	Lithium, quetiapine, valproic acid, asenapine, aripiprazole, paliperidone, risperidone, cariprazine Combination with mood stabiliser: quetiapine, aripiprazole, risperidone, asenapine	Olanzapine, carbamazepine, olanzapine + lithium (or valproic acid), lithium + valproic acid, ziprasidone, haloperidol, ECT	Carbamazepine + lithium (or valproic acid), chlorpromazine, clonazepam, clozapine, haloperidol + lithium (or valproic acid), rTMS, tamoxifen, tamoxifen + lithium (or valproic acid)
Bipolar depression	Quetiapine, lurasidone + lithium (or valproic acid), lamotrigine, lamotrigine (adj)	Valproic acid, SSRI/bupropion (adj), ECT, cariprazine, olanzapine–fluoxetine complex	Carbamazepine, adj: olanzapine, SNRI/MAOI, modafinil, eicosapentaenoic acid, rTMS, ketamine, light therapy/sleep deprivation, levothyroxine, N-acetylcysteine, pramipexole, aripiprazole, armodafinil, asenapine
Mixed features	Mixed mania: none determined Mixed depression: none determined Mixed features without predominance: asenapine, aripiprazole	Mixed mania: asenapine, cariprazine, valproic acid, aripiprazole Mixed depression: cariprazine, lurasidone Mixed features without predominance: olanzapine + mood stabiliser, carbamazepine, olanzapine, valproic acid	Mixed mania: ziprasidone, olanzapine, olanzapine + mood stabiliser, quetiapine, carbamazepine, ECT Mixed depression: olanzapine, olanzapine fluoxetine complex, quetiapine, valproic acid, lamotrigine, ziprasidone, ECT Mixed features without predominance: ziprasidone, valproic acid + carbamazepine, cariprazine, lithium + valproic acid, ECT
Rapid-cycling bipolar disorder	No recommendation	No recommendation	No recommendation
Maintenance treatment	Lithium, quetiapine, valproic acid, lamotrigine, asenapine, quetiapine + lithium (or valproic acid), aripiprazole + lithium (or valproic acid), aripiprazole, aripiprazole once monthly	Olanzapine, risperidone LAI, risperidone LAI (adj), carbamazepine, paliperidone, lurasidone + lithium (or valproic acid), ziprasidone + lithium (or valproic acid)	Aripiprazole + lamotrigine, olanzapine fluoxetine complex, clozapine (adj), gabapentin (adj)

adj, adjuvant; CANMAT, Canadian Network for Mood and Anxiety Treatments; ECT, electroconvulsive therapy; LAI, long-acting injectable; MAOI, monoamine oxidase inhibitor; rTMS, repetitive transcranial magnetic stimulation; SNRI, serotonin–noradrenaline reuptake inhibitor; SSRI, selective serotonin reuptake inhibitor.