maintenance treatment

Last edited 08/2018

• all forms of affective disorder are likely to relapse
• requires specialist advice
• long-term drug therapy can play a crucial role in reducing the frequency and severity of acute episodes of mania and depression in patients with bipolar disorder.
  • NICE state that lithium should be offered as a first-line, long-term pharmacological treatment for bipolar disorder and:
    • if lithium is ineffective, consider adding valproate
    • if lithium is poorly tolerated, or is not suitable (for example, because the person does not agree to routine blood monitoring), consider valproate or olanzapine instead or, if it has been effective during an episode of mania or bipolar depression, quetiapine
      
      
  • do not use long-acting intramuscular injections of antipsychotics routinely. But they may be considered for people whose mania has responded to oral antipsychotics, but have had a relapse because of poor adherence
    
    
  • length of treatment
    • normally, long-term pharmacological treatment should last for (2):
      • at least 2 years after an episode of bipolar disorder
      • up to 5 years if the person has risk factors for relapse, such as a history of frequent relapses or severe psychotic episodes, comorbid substance misuse, ongoing stressful life events, or poor social support

Notes (1):

• valproate in women of childbearing potential
  • do not offer valproate to women of childbearing potential for long-term treatment or to treat an acute episode
  • if a woman of childbearing potential is already taking valproate, advise her to gradually stop the drug because of the risk of fetal malformations and adverse neurodevelopmental outcomes after any exposure in pregnancy

Reference:

1. NICE (April 2018). Bipolar disorder.
2. Drug and Therapeutics Bulletin 2005; 43(5):33-6..