DISCONTINUATION OF MAINTENANCE TREATMENT IN BIPOLAR DISORDER - RISKS AND IMPLICATIONS

There is abundant evidence for substantial long-term prophylactic effi cacy of lithium in bipolar manic-depressive disorders. Interruption of such treatment carries an extraordinarily high risk of recurrence wit hin several months, even after several years of stability. Even a shar p reduction in dose may carry some risk. Gradual discontinuation of li thium was accompanied by markedly reduced risk of early recurrence. Th ere is suggestive evidence that the phenomenon of high risk of recurre nce after abrupt interruption of maintenance treatment may occur with other disorder and treatments, including neuroleptics in schizophrenia and possibly antidepressants in recurrent depression. The phenomenon of discontinuation-associated iatrogenic risk of early recurrence of m ajor psychiatric illness has clear clinical implications. These includ e the need to evaluate safer methods of interrupting long-term mainten ance treatment, particularly when clinical indications tor rapid cessa tion are compelling and gradual discontinuation is not feasible. Quest ions also arise concerning interpretation of existing experimental stu dies of maintenance treatments that require interruption of treatment, reduction of dose, or crossover to a placebo, as well as the ethical and scientifically unambiguous design of future studies of this kind.