Long-term treatment of bipolar disorder

Lithium was one of the first effective drugs to be introduced to psychotherapeutics, and it remains an important treatment both for mania and for the prophylaxis of bipolar disorder. Its action in preventing recurrences appears greater against mania than against depression. A major trend in recent years has been the recognition that antipsychotic drugs are useful not only in mania and hypomania, but in preventing both mania and depression in patients with bipolar I disorder. The antiepileptic agent lamotrigine is useful in preventing depression and to a lesser extent in preventing mania in bipolar I disorder and in bipolar II rapid cycling. The place of valproate or carbamazepine in long-term treatment has not been firmly established. The effectiveness of lithium is limited by side effects and poor compliance. There is growing evidence that certain antipsychotic agents are associated with better compliance and greater effectiveness than lithium, although their metabolic and endocrine side effects can be problematic. Recent Guidelines recognise the role of antipsychotics in the long-term management of bipolar disorder, alongside lithium, lamotrigine and sometimes antidepressants.