Bipolar disorder: Strategies for the lifelong illness

Abstract

Bipolar disorder has a lifelong course. Our understanding of the illness is not complete enough to detect it before the first manic or hypomanic episode. Treatment of bipolar disorder has three phases. The continuation phase comprises the transition between symptomatic improvement after correct diagnosis and effective treatment of an episode and functional recovery. This phase requires continuation of effective pharmacologic treatments combined with nonpharmacologic treatments that will provide the basis for education, monitoring, and anticipation of relapse. The maintenance phase begins when pre-episode function has been regained. Placebo-controlled data for mania support lithium, olanzapine, and divalproex in patients whose most recent episode responded to one of these treatments. Carbamazepine lacks placebo-controlled studies but appears to have response predictors that are complementary to those of lithium. For prevention of depressive episodes, which are at least twice as frequent as mania, placebo-controlled data support lithium, lamotrigine, and divalproex. Treatment response may depend upon the course of illness. There are relatively little data about long-term treatment response in bipolar II disorder or rapid-cycling. Although current treatments are effective, especially when combined with appropriate nonpharmacologic treatments, more definitive strategies require a better understanding of the physiologic processes underlying the recurrent nature of bipolar disorder.