Findings of Bipolar Disorder Studies in Low/Lower-Middle Income Countries Largely Align With International Guidelines

Investigators searched publication databases through November 2021 for studies of bipolar disorder conducted in low- and lower middle-income countries

A systematic review found that more study is needed to evaluate treatment of bipolar disorder (BD), particularly during depressive episodes, in low or lower-middle income countries. These findings were published in the Journal of Affective Disorders.

Investigators from Aarhus University in Denmark and the College of Medicine and Health Sciences University of Rwanda searched publication databases through November 2021 for studies of BD conducted in low- and lower middle-income countries. Country income was based on World Bank ranking. The outcomes of interest were symptom severity, relapse, recovery, medical adherence, quality of life, psychosocial functioning, and level of stigma.

A total of 21 studies published between 1998 and 2021 were included in this review. A total of 2 trials were of nonrandomized designs and the remaining 19 were randomized clinical trials. The studies were conducted in Pakistan, India, China, Egypt, Iran, and South Africa.

The studies investigated 4 types of interventions: pharmacotherapy, psychosocial, electroconvulsive therapy, and traditional medicine.

Despite the fact that individuals with BD spend more time in a depressed state, only 2 of the studies focused on BD depression.

In the studies investigating pharmacotherapy and traditional medicine, only 1 study included maintenance therapy follow-up. Overall, the studies supported the use of quetiapine, risperidone, and risperidone combined with valproate for the management of BD mania. These data are in line with international guidelines. Another study supported the use of electroconvulsive therapy, also in line with guidelines.

Group or individual psychoeducation interventions were found to have effects on symptom severity, medical adherence, and quality of life; however, sample sizes were low. One study found that including a family component to psychoeducation enhanced clinical outcomes. These findings were in line with results from studies conducted in Western societies.

This review was limited by the low number of studies available and the overall weak quality of data.

The study authors concluded, “The exceptionally small number of intervention trials on BD in low- and lower-middle-income countries is a call for action and attention, including an increase in targeted funding opportunities for research in BD and prioritization of capacity building of local researchers and their environment.”


Arnbjerg CJ, Rurangwa NU, Musoni-Rwililiza E, Gishoma D, Carlsson J, Kallestrup P. Intervention trials for adults with bipolar disorder in low-income and lower-middle-income countries: A systematic review. J Affect Disord. 2022;311:256-266. doi:10.1016/j.jad.2022.05.097