Managing bipolar disorder from urgent situations to maintenance therapy, Part 2: Focus on maintenance

Abstract

Dr. Jain stressed that, to fully embrace the cause of maintenance treatment of bipolar disorder, clinicians must first acknowledge the dangers of less-than-optimum maintenance treatment. These dangers include high relapse and recurrence rates, reduced treatment adherence, and adverse neurobiological effects. Several general rules apply to maintenance treatment of bipolar disorder. First, clinicians should routinely offer maintenance treatment because patients often relapse. Second, when selecting pharmacotherapy, multiple issues are important, including the patient's individual needs, the efficacy and side effect burden of individual medications, FDA-approved medications for bipolar maintenance therapy available in the patient's insurance formulary, and the quality of research data. Dr. Jain stated that antidepressants should usually be avoided, especially as monotherapy. While monotherapy mood stabilizer treatment is preferred, combination therapy is indicated if treatment response is suboptimum. A large number of pharmacologic treatment options are available for maintenance treatment, including the FDA-approved medications lithium, lamotrigine, olanzapine, and aripiprazole, as well as other agents such as divalproex, carbamazepine, oxcarbazepine, and atypical antipsychotics, which can be used as monotherapy or as part of combination therapy. Third, psychotherapy has become increasingly well-studied and can be used for the majority of patients as an adjunctive treatment strategy. Psychotherapy for bipolar disorder can delay recurrence, stabilize symptoms, and improve medication adherence.99 Additionally, several types of psychotherapy are available that can be useful to augment the benefits of mood stabilizers, such as group psychoeducation, family-focused therapy, interpersonal and social rhythm therapy, and cognitive-behavioral therapy.100 Dr. Jain asserted that, while patient adherence is important for treatment to succeed, clinician adherence to treatment guidelines is also vital. A recent survey 101 of psychiatrists revealed that only 64% of clinicians reported routinely using any treatment guidelines in making clinical decisions, which leaves room for improvement. Dr. Jain also recommended the use of daily mood ratings to both psychiatrists and nonpsychiatrists to track the progress of patient treatment. Clinical experience and research data102 show that maintaining daily mood ratings can be useful for both patients and clinicians to detect relapse earlier during treatment than without these ratings. The need for maintenance treatment is now widely recognized, and clinicians now have access to multiple tools to ensure optimum maintenance out-comes for patients. Dr. Jain concluded that carefully matching a patient's unique needs with individual treatment interventions is the ideal path to achieving high rates of success.