The clinical management of bipolar disorder complexity using a stratified model

Gin S. Malhi, Danielle M. Bargh, Emma Cashman, Mark A. Frye, Michael Gitlin

Research output: Contribution to journalReview articlepeer-review

39 Scopus citations


Objective: To provide practical and clinically meaningful treatment recommendations that amalgamate clinical and research considerations for several common, and as yet understudied, bipolar disorder complex presentations, within the framework of a proposed stratified model. Methods: A comprehensive search of the literature was undertaken using electronic database search engines (Medline, PubMed, Web of Science) using key words (e.g., bipolar disorder, anxiety, rapid cycling, and subsyndromal). All relevant randomised controlled trials were examined, in addition to review papers, meta-analyses, and book chapters known to the authors. The findings formed the basis of the treatment recommendations within this paper. Results: In light of the many broad presentations of bipolar disorder, a stratified model of bipolar disorder complexity was developed to facilitate consideration of the myriad of complexities that can occur during the longitudinal course of illness and the appropriate selection of treatment. Evidence-based treatment recommendations are provided for the following bipolar disorder presentations: bipolar II disorder, subsyndromal symptoms, mixed states, rapid cycling, comorbid anxiety, comorbid substance abuse, and for the following special populations: young, elderly, and bipolar disorder around the time of pregnancy and birth. In addition, some key strategies for countering treatment non-response and alternative medication recommendations are provided. Conclusions: Treatment recommendations for the more challenging presentations of bipolar disorder have historically received less attention, despite their prevalence. This review acknowledges the weaknesses in the current evidence base on which treatment recommendations are generally formulated, and additionally emphasises the need for high-quality research in this area. The stratified model provides a means for conceptualizing the complexity of many bipolar disorder presentations and considering their management.

Original languageEnglish (US)
Pages (from-to)66-89
Number of pages24
JournalBipolar disorders
Issue numberSUPPL.2
StatePublished - May 2012


  • Acute treatment
  • Bipolar disorder
  • Evidence-based review
  • Guidelines
  • Maintenance treatment
  • Treatment

ASJC Scopus subject areas

  • Psychiatry and Mental health
  • Biological Psychiatry


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