APA Practice Guidelines

C. Maintenance Treatment of Bipolar Disorder

cont. from

Maintenance medication treatment is generally recommended following a single manic episode. Although few studies have been conducted involving patients with bipolar II disorder, consideration of maintenance treatment for this form of the illness is also warranted. Primary goals of treatment include relapse prevention, reduction of subthreshold symptoms, and reduction of suicide risk. Goals also need to include reduction of cycling frequency and mood instability as well as improvement in overall functioning. Pharmacotherapy must be employed in ways that yield good tolerability and do not predispose the patient to nonadherence.

Options with the best empirical evidence to support their use as maintenance treatments include lithium or valproate; possible alternatives include lamotrigine, carbamazepine, or oxcarbazepine. Despite limited data, oxcarbazepine is included-as it was for acute treatment of mania-because its efficacy may be similar to that of carbamazepine but with better tolerability. In general, if one of these medications was used to achieve remission from the most recent depressive or manic episode, it should be continued. Maintenance ECT may also be considered for patients whose acute episode responded to ECT. Selection of the initial treatment should be guided by clinical factors such as illness severity, by associated features (e.g., rapid cycling, psychosis), and by patient preference, with particular attention to side effect profiles.

For patients treated with an antipsychotic medication during the preceding acute episode, the need for ongoing antipsychotic treatment should be reassessed upon entering the maintenance phase. Since antipsychotic agents, particularly typical antipsychotics, may cause tardive dyskinesia with long-term use, antipsychotics should be slowly tapered and discontinued unless they are required to control persistent psychosis or provide prophylaxis against recurrence. While maintenance therapy with atypical antipsychotics may be considered, there is as yet no definitive evidence that their efficacy in maintenance is comparable to that of agents such as lithium or valproate.

Patients with bipolar disorder are likely to gain some additional benefit during the maintenance phase from a concomitant psychosocial intervention that addresses illness management (i.e., adherence, lifestyle changes, and early detection of prodromal symptoms) and interpersonal difficulties. Although not adequately studied to provide evidence-based documentation, supportive and psychodynamic psychotherapy are widely used in addition to medication.

Group psychotherapy, in conjunction with appropriate medication, may also help patients address such issues as adherence to a treatment plan, adaptation to a chronic illness, regulation of self-esteem, and management of marital as well as other psychosocial issues.

Support groups provide useful information about bipolar disorder and its treatment. Patients in these groups often benefit from hearing the experiences of others who are struggling with such issues as denial versus acceptance of the need for medication, problems with side effects, and how to shoulder other burdens associated with the illness and its treatment. Advocacy groups such as the National Depressive and Manic-Depressive Association and the National Alliance on Mental Illness (Appendix I) have many local chapters that provide both support and educational material to patients and their families.

Although maintenance medication combinations are often associated with increases in side effects, use of such regimens should be considered for patients who have not responded adequately to simpler regimens. The addition of another maintenance medication, an atypical antipsychotic, or an antidepressant may be necessary for patients who experience either continuing high levels of subthreshold symptoms or a breakthrough episode of illness. There are currently insufficient data to support one combination over another. Maintenance ECT may also be considered for patients whose acute episode responded to ECT.

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Written 4/02. Reviewed: 03/2006