Bipolar disorder therapeutics: Maintenance treatment

Although most of the care received by bipolar patients occurs during the ma intenance phase, relatively little empirical data is available to guide lon g-term treatment decisions. We review literature pertaining to key question s related to use of pharmacotherapy in the maintenance phase of bipolar dis order. The few double-blind trials with a reasonable sample size are restri cted to bipolar I patients and address a modest range of questions mostly r elated to use of lithium. One rigorous multicenter trial found valproate to have prophylactic benefit. Other studies with valproate alone and in combi nation suggest efficacy equivalent to lithium and perhaps greater than carb amazepine. Data available for combination treatment are sparse but moderate ly encouraging. Maintenance treatment with standard antidepressant medications appears dest abilizing for some bipolar patients, particularly following a mixed episode . Although some bipolar patients may benefit from combined treatment with a mood stabilizer and a standard antidepressant medication, current knowledg e does not allow confident selection of the bipolar patients who might bene fit Clozapine and perhaps other atypical antipsychotics are promising optio ns for maintenance treatment but have not been evaluated in double-blind tr ials. The numerous other agents used in maintenance treatment are primarily adjuncts to lithium, valproate, or carbamazepine, and information about th em is largely anecdotal and uncontrolled. Study design for maintenance trials remains an imperfect art. Conclusions m ust be drawn cautiously, given the limited generalizability of study design s that accession samples enriched with presumed treatment responders, rando mize patients after brief periods of partial remission, abruptly taper prio r treatment, make no attempt to distinguish relapse from recurrence, use no formal outcome assessments, or report hospitalization as the only outcome criterion. (C) 2000 Society of Biological Psychiatry.