Table 2.
App quality assessment statements derived from BD treatment guidelines and meta-analyses.
| Statement | Associated guideline |
| 1. Initiation of an atypical antipsychotic and/or mood stabilizer for the treatment of acute mania. | “Efficacy of lithium and divalproex is well established…substantial RCT data support atypical antipsychotic monotherapy with olanzapine, risperidone ER, quetiapine, ziprasidone, and aripiprazole for the first-line treatment of acute mania” Yatham et al, 2013, pp 4, 6 [19] |
| “Overall, risperidone, olanzapine, and haloperidol seem to be the most effective evidence-based options for the treatment of manic episodes” Cipriani et al, 2011, pp 1314 [20] | |
| 2. Use of an atypical antipsychotic or mood stabilizer, with or without an antidepressant, for the treatment of bipolar depression. | “Lithium, lamotrigine, quetiapine…monotherapies, as well as lithium or divalproex plus selective serotonin reuptake inhibitor, olanzapine plus SSRI…recommended as first-line choices for bipolar depression” Yatham et al, 2013, pp 9 [19] |
| “Adjunctive antidepressants may be used for an acute bipolar I or II depressive episode when there is a history of previous positive response to antidepressants” Pacchiarotti et al, 2013, pp 1253 [21] | |
| 3. Antidepressant subtypes tricyclic antidepressants and serotonin-norepinephrine reuptake inhibitors (SNRIs) are more likely to cause switching than serotonin-specific reuptake inhibitors (SSRIs). | “The risk of mood switching is considered to be…somewhat greater with tri-and tetracyclics (and perhaps some SNRIs) than with most modern antidepressants” Pacchiarotti et al, 2013, pp 1256 [21] |
| “monotherapy with some antidepressants, especially tricyclics, without an accompanying mood stabilizer, however, may be associated with an increased rate of treatment emergent affective switches (TEAS)” Grunze et al, 2010, pp 92 [17] | |
| 4. Lithium, an atypical antipsychotic, or lamotrigine (where depression predominates) for maintenance treatment of BD. | “Lithium, divalproex, olanzapine, and quetiapine, as well as lamotrigine (primarily for preventing depression)…continue to be first-line monotherapy options for maintenance treatment of BD” Yatham et al, 2013, pp 14 [19] |
| “Lithium, olanzapine or valproate should be considered for long-term treatment of bipolar disorder” NCCMH, 2006, pp 5 [23] | |
| 5. Change monotherapy or use combination therapy for treatment resistance. | “No response after 2 weeks, switch to another first choice medication, in severe mania, consider combination” Grunze et al, 2009, pp 104 [16] |
| “If the patient has frequent relapses, or symptoms continue to cause functional impairment, switching to an alternative monotherapy or adding a second prophylactic agent should be considered.” NCCMH, 2006, pp 5 [23] | |
| 6. The use of electroconvulsive therapy (ECT) for treatment resistant acute symptoms (particularly depression, but also mania). | “Especially in very severe and psychotic depression, or in depression with severe psychomotor retardation, ECT has a major role” Grunze et al, 2010, pp 100 [17] |
| “ECT is recommended for bipolar depression after an antidepressant trial has failed” RANZCP, 2004, pp 288 [22] | |
| “ECT is still a valuable last resource in severe delirious mania which is otherwise treatment refractory” Grunze et al, 2009, pp 102 [16] | |
| 7. Careful monitoring of blood levels is required where those correlate with treatment response (eg, lithium, valproate). | “Plasma concentrations need to be checked on a frequent and regular basis until equilibrium in the therapeutic range as been achieved and thereafter. It is recommended to check every 3-6 months” Grunze et al, 2013, pp 186 [18] |
| “lithium is up titrated in small steps guided by individual experience and plasma level monitoring” Grunze et al, 2013, pp 186 [18] | |
| 8. Careful monitoring of potential physical complications or side effects of treatments is required (eg, kidney, thyroid, and calcium with lithium; glucose and lipids with antipsychotics). | “Renal and thyroid function should also be checked regularly, every 6-12 months depending on risks” Grunze et al, 2013, pp 186 [18] |
| “Complete medication and laboratory investigations should be performed at baseline, with ongoing monitoring for weight changes and adverse effects of medication” Yatham et al, 2013, pp 29 [19] | |
| 9. Women informed about ensuring that their medications are safe to take during breastfeeding and pregnancy. | “Important that women with bipolar disorder receive education early in the course of illness about the effects of mood stabilizing and other medications on contraceptive effectiveness, as well as the need to plan medication management during pregnancy and the postpartum period” Yatham et al, 2005, pp 33 [24] |
| 10. Seek medical professional advice and/or a second opinion in diagnosis of BD in children, due to the controversy in this area. | “The presentation and diagnosis of BD in children and adolescents remains controversial…diagnostic criteria for BD may not be systematically applied in some clinical settings.” Yatham et al, 2013, pp 19 [19] |
| 11. Outlines difficulties in the treatment of rapid cycling BD. | “Rapid cycling…is associated with greater severity of illness on a number of clinical measures” Yatham et al, 2005, pp 30 [24] |
| “The prophylactic use of lithium in rapid cycling patients has been discouraged for a long time based on the observation of insufficient acute and prophylactic efficacy in these patients” Grunze et al, 2013, pp 184 [18] | |
| 12. Optimal treatment for most patients with BD will include psychological treatment as well as medication. | “When used as adjuncts to pharmacotherapy, psychosocial interventions…have demonstrated significant benefits, both in the treatment of acute depressive episodes and also as long-term maintenance treatment…providing psychological treatments—and, in particular, brief psychoeducation, which has been demonstrated to be as effective as CBT at much lower cost—is an essential aspect of managing patients with BD” Yatham et al, 2013, pp 4 [19] |
| “The primary long-term treatments are pharmacological, but psychological and psychosocial interventions have an important part to play” NCCMH, 2006, pp 33 [23] | |
| 13. Indicates that most patients benefit considerably from treatment for their BD. | “The advent of these therapies, both drug and psychological, means that the majority of patients with this recurrent and disabling condition may be effectively treated” RANZCP, 2004, pp 299 [22] |