COURSE OF ILLNESS AND MAINTENANCE TREATMENTS FOR PATIENTS WITH BIPOLAR DISORDER

Background: Both naturalistic studies and treatment research on bipola r disorder are reviewed to describe its clinical course, the need for maintenance therapy, the efficacy of current pharmacologic prophylaxis , and the empirical basis for more comprehensive approaches to treatme nt. Method: Articles were identified through computerized literature s earches and from bibliographies of published studies, review articles, and textbooks. Results: Bipolar disorder is marked by multiple relaps es and recurrences, as well as significant interepisode psychopatholog y. Within 1 year of recovery from a mood episode, half of all patients will have suffered a second episode. Various clinical and demographic variables have been investigated as risk factors for recurrence. Alth ough lithium represents the single greatest advance in the treatment o f this disease, it is clear that a substantial number of patients fail lithium prophylaxis, including those with a high frequency of prior e pisodes, mixed (dysphoric) mania, comorbid personality disturbance, an d rapid cycling. The foremost pharmacologic alternatives to lithium ar e the anticonvulsants carbamazepine and valproate. Increased recogniti on of the psychosocial sequelae of bipolar disorder and the limitation s of pharmacotherapy alone have led to the investigation of psychosoci al interventions. These preliminary studies are small in number and of poor quality for the most part, but have nevertheless yielded positiv e findings. Conclusion: Although lithium often fails to meet the clear ly established need for prophylactic treatment, there is little eviden ce from rigorous clinical trials to support the widespread use of anti convulsants in maintenance therapy. Treatment research should further examine these medications and the use of psychosocial treatments as ad juvants to pharmacotherapy.