SYMPOSIA

References:
Bulletin of Clinical Psychopharmacology, Vol: 21, Supplement: 2, 2011 - www.psikofarmakoloji.org
Abstracts of the Invited Speakers
1. Fountoulakis KN, Vieta E, Sanchez-Moreno J, Kaprinis SG, Goikolea JM, Kaprinis GS. Tretament guidelines for bipolar disorder: A critical review. J Affective Dis 2005;
86: 1-10.
2. Perlis RH. Use of treatment guidelines in clinical decision making in bipolar diorder: a pilot survey of clinicians. Curr Med Res Opin 2007; 23; 467-475.
3. Samalin L, Guillaume S, Auclair C, Llorca PM. J Nerv Ment Dis 2011; 199: 239-243.
Bulletin of Clinical Psychopharmacology 2011;21(Suppl. 2):S98-9
Maintenance treatment in bipolar disorder: What do guidelines recommend?
Ibrahim Eren
Konya Research and Training Hospital, Psychiatry Department, Konya, Turkey
E-mail: drieren@yahoo.com
Bipolar disorder is a serious mental illness presenting with exacerbations and remissions. Relapses should be minimized and that is
achieved by preventive treatments. Developing easily applicable and reachable algorithms by incorporating data coming from various
sources, implementing research findings in daily practice, and providing standardized treatment choices are all important. Many
guidelines have been published for bipolar disorders so far.
American Psychiatric Association (APA) Guidelines: This guidelines recommend preventive treatment after one manic episode. The
main goals of treatment are to prevent relapse, resolve subclinical residual symptoms, and to decrease suicide risk. Lithium and valproate
are primary agents, as they have the most evidence of efficacy. Their alternatives lamotrigine, carbamezapine, and oxscarbamezapine are
secondary agents. In general continuation of preventive medications used during acute management is first choice during maintenance
treatment. ECT can be used as a maintenance treatment. Antipsychotics should be discontinued if there is no persistent psychotic symptoms.
Cognitive behavioral, interpersonal, and psychodynamic therapies can be used in addition to medications. Psychoeducation is reported
to be beneficial. Keeping lithium levels between 0.8-1.0 mEg/L during maintenance phase were mentioned to be more effective. In this
guideline generally accepted treatments were mentioned as non-definite recommendations.
Texas Medication Algorithm: Acute phase doses should be continued at least 3 months. All patients are recommended to receive
antimanic medications during maintenance phase, if necessary some can receive low dose antidepressants. Lifelong maintenance
treatment is recomended if patients had 2 manic episodes or one manic episode with positive family history, or the acute episode was
very severe. This group of authors think antimanic medications are the core of the treatment and they emphasize depression less. In
addition they recommend ECT and tricyclics, which were demonsterated to be effective, in final stages due to side effects and patient
preferences.
Expert Opinion Series on Medication Treatment in Bipolar Disorder: They recommend continuation of treatment, which was effective
in acute phase except in divalproex monotherapy and predominantly depressive cases. They suggest adding lithium in those cases.
They recommend that antipsychotics should be stopped during maintenance phase, but some patients may need to continue taking
antipsychotics. In that case, one of olanzapine, risperidone, or quetiapine can be chosen. Against manic episode risk they suggest to
increase the dose of mood stabilizer, add another mood stabilizer, and try additional treatments afterwards. This algorithm has many
structural features and is very detailed.
British Psychopharmacology Association Guidelines: According to this guideline lithium is the first choice and second choice
medications include valproate, olanzapine, carbamazepine, oxcarbazepine, and lamotrigine. Treatment resistant cases can be treated with
medication combinations, clozapine, or ECT.
World Federation of Biological Psychiatry Associations Biological Treatments in Bipolar Disorders: It is recommended to use
combination of antidepressant and mood stabilizers after depressive episodes. After manic episodes lithium, anticonvulsants, or
antipsyhotics are suggested. When first line treatments fail, trying combinations of first line agents is recommended. It seems to be
the most balanced guideline published so far. While they avoid newly discovered treatments , they support use of antipsychotics and
antidepressants with caution.
Canmat: Once the patient becomes asymptomatic, it is suggested to discontinue all medications other than mood stabilizers and to
continue maintenance treatment for 6-12 months after a single episode of illness. This guideline has similarities with APA guideline and
recommends lifelong maintenance treatment in patients with recurrent episodes or positive family history.
Australia and New Zealand Bipolar Disorder Treatment Algorithm: It suggests to avoid antidepressant use during maintenance phase
after depressive episodes due to precipitating mania and rapid cycling, but recommends mood stabilizer and antidepressant use in cases
with recurrent depressive episodes. The duration of treatment after first manic episode is 6 months and lithium, valproate, carbamazepine,
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