Maintenance studies in bipolar disorder have received increased attent
ion in recent years. The interest is driven by apparent contradictions
between results of early placebo-controlled trials of lithium and rec
ent open studies, as well as interest in a new group of drugs with moo
d-stabilizing properties. The multiple outcome indices that require at
tention in prophylactic bipolar disorder studies add a dimension not p
resent in acute studies of bipolar disorder. We present the methodolog
y of a recently completed randomized, double-blind, placebo-controlled
, parallel-group comparison of divalproex and lithium. We examine the
consequences of salient design features, along with their implications
for future studies. A fundamental conclusion is that such maintenance
studies should be designed and executed to emphasize enrollment of pa
tients with relatively active, severe forms of the illness. This goal
is not achieved simply, as inherent features of long-term, placebo-con
trolled studies drive recruitment and enrollment in the direction of p
atients with milder forms of bipolar disorder. Attention to the freque
ncy of both manic and depressive episodes and the severity of an index
manic episode may aid in the selection of patients most suitable for
studies designed to achieve adequate statistical power.