Korean medication algorithm for bipolar disorder (KMAP-BP): Changes in treatment strategies for bipolar depression over 12 years

Introduction Many guidelines for bipolar disorders have been introduced based on evidences. In contrast, KMAP-BP was developed by an expert-consensus. Objective To summarize the medication strategies for bipolar depression over four published KMAP-BP (2002, 2006, 2010, and 2014). Methods The questionnaire using a nine-point scale had covered some clinical situations with many treatment options about the appropriateness of treatment. Results For mild-to-moderate depression, antidepressant (AD) + mood stabilizer (MS) in early editions and MS or lamotrigine monotherapy and AAP + (MS or lamotrigine) in later editions were preferred strategies. For severe nonpsychotic depression, MS + AD was the only first-line medication in early editions. In 2014, various medications [MS + AAP (atypical antipsychotic), AAP + lamotrigine, MS + AD] were preferred. Valproate and lithium has been rated as first-line MS in all editions. Lamotrigine were positively preferred later. Adjunctive AD was accepted as first-line strategy for severe depression in all editions. Preference of AAP also has been increased remarkably. Adjunctive AAP was not first-line treatment for mild-to-moderate depression in all editions, but was for nonpsychotic depression in 2010 and 2014 and for psychotic depression in all editions. Recommended AAPs have been changed over 12 years: olanzapine and risperidone in 2002 and quetiapine, aripiprazole, and olanzapine in 2014 were first-line AAP. Conclusion There have been evident preference changes: increased for AAP and lamotrigine and decreased for AD. The high preferences for aripiprazole and lamotrigine in later editions were likely derived from favorable tolerability.