Le trouble bipolaire est une maladie récurrente sévère reconnue par l’Organisation mondiale de la santé (OMS) comme la septième cause de handicap par année de vie parmi toutes les maladies dans la population des 15 à 44ans. Le handicap majeur conféré par cette pathologie est lié au très haut niveau de rechute, à l’impact fonctionnel des comorbidités associées et des troubles cognitifs entre les épisodes. L’utilisation systématique par les cliniciens d’algorithmes décisionnels issus des recommandations améliore la prise en charge globale des patients bipolaires, en comparaison à une modalité de traitement habituel. Bien qu’elles n’embrassent pas l’ensemble des situations rencontrées avec les patients, cette approche systématique contribue au développement d’une médecine personnalisée, indispensable dans cette pathologie. Notre revue synthétise les recommandations internationales les plus récentes dans la prise en charge des phases maniaques. De manière consensuelle, les recommandations proposent en première intention l’utilisation des stabilisateurs de l’humeur traditionnels (lithium ou valproate) et des antipsychotiques atypiques (APA – olanzapine, rispéridone, aripiprazole et quétiapine), ainsi que l’arrêt des antidépresseurs. Les recommandations sont divergentes concernant l’utilisation des combinaisons thérapeutiques proposées soit en traitement de première intention pour les cas sévères, soit en seconde intention. Le traitement des états mixtes est aussi peu consensuel et quelques recommandations proposent le valproate, la carbamazépine et certains APA en première intention, en déconseillant l’utilisation du lithium. Enfin, la durée du traitement des phases maniaques est non consensuelle.

Bipolar disorder (BD) is the seventh leading cause of disability per year of life among all diseases in the population aged 15 to 44. It is a group of heterogeneous diseases, with frequent comorbid psychiatric or somatic disorders, variable treatment response and frequent residual symptoms between episodes. The major impairment associated with this disorder is related to the high relapse and recurrence rates, the functional impact of comorbidities and cognitive impairment between episodes. The prognosis of the disease relies on the efficacy of relapse and recurrence prevention interventions. Given the heterogeneity of the disorder, relapse and recurrence prevention needs to develop a personalized care plan from the start of the acute phase. In such a complex situation, guideline-driven algorithms of decision are known to improve overall care of patients with bipolar disorder, compared to standard treatment decisions. Although guidelines do not account for all the situations encountered with patients, this systematic approach contributes to the development of personalized medicine.

We present a critical review of recent international recommendations for the management of manic phases. We summarize treatment options that reach consensus (monotherapy and combination therapy) and comment on options that differ across guidelines.

The synthesis of recent international guidelines shows a consensus for the initial treatment for manic phases. For acute and long-term management, the anti-manic drugs proposed are traditional mood stabilizers (lithium or valproate) and atypical antipsychotics (APA – olanzapine, risperidone, aripiprazole and quetiapine). All guidelines indicate stopping antidepressant drugs during manic phases. International guidelines also present with some differences. First, as monotherapy is often non sufficient in clinical practice, combination therapy with a traditional mood stabilizer and an APA are disputed either in first line treatment for severe cases or in second line. Second, mixed episodes treatment is not consensual either and some guidelines propose in first line valproate, carbamazepine and some APA, and advice not to use lithium. On the other hand, some guidelines do not propose specific treatment for mixed episodes and group them with manic episodes management. Duration of treatment is unclear.

Guidelines utilization has shown that the systemic use by clinicians of decision algorithms in comparison to “treatment as usual” modality improves the overall care of patients with BD. Future data from cohorts of patients seem necessary to complement the existing data from clinical trials. These cohort studies will help to take into account the different individual profiles of BD and thus may help to propose a more personalized medicine.