Maintenance therapies for classic and other forms of bipolar disorder

The progressive, episodic and chronic nature of bipolar disorder dictates t he need for lifelong pharmacological maintenance treatment in the majority of patients. Prophylaxis should be considered after a single episode of sev ere mania or after more than one episode of hypomania in bipolar II disorde r, although some clinicians now consider an episode of either sufficient to warrant maintenance therapy. Lithium is efficacious as maintenance therapy , but is not as highly effective as early studies initially suggested (abru pt discontinuation of lithium probably increased placebo relapse figures). Rates of premature discontinuation of lithium are high. Divalproex sodium i s used frequently in the USA and Canada for long-term treatment for bipolar disorder but an insufficient number of controlled trials have been publish ed to assess adequately its role. Carbamazepine is also employed in mainten ance treatment. Randomized studies indicate it is superior to placebo but s omewhat less effective than lithium. Augmentation of any of these drugs wit h another mood stabilizer, an antipsychotic, or electroconvulsive therapy a ppears to be effective, although there are few controlled studies. Design i ssues that need consideration in order to achieve meaningful data are discu ssed. A severe manifestation of bipolar disorder is rapid cycling. It is of ten induced by antidepressants, although this association frequently goes u nrecognized. Patients with a rapid cycling course of illness are difficult to treat effectively. Although rapid cycling is often associated with poor response to lithium, there have been no randomized, controlled treatment st udies. Based on open studies and expert panel recommendations, the Internat ional Exchange on Bipolar Disorder (LEBD) recommended initial treatment wit h divalproex sodium, with subsequent addition of other mood stabilizers, an tipsychotics or thyroid supplementation as necessary. Combination treatment s are frequently required for optimal response in these patients. (C) 2000 Elsevier Science B.V. All lights reserved.