Appendix: Multiphase Treatment Strategy for Bipolar Disorder

See

Figure 45-4 and

Figure 45-5.

Acute Phase
The acute phase begins when the disorder meets the criteria for an episode (depression, mania, hypomania, or mixed) and treatment is initiated. Each individual acute-treatment trial is carried out to one of three endpoints:

1.  Treatment is discontinued because the patient is unable to tolerate adverse effects of treatment.

2.  Treatment is discontinued because the patient has not responded to a maximal trial of the treatment (including, if warranted, augmentation strategies).

3.  The patient has improved during this treatment.

Problems during the acute phase include treatment intolerance, inadequate dosage, partial response, and nonresponse. Treatments are adjusted or replaced as necessary to manage these problems until the acute symptoms remit, ending the acute phase.

Continuation Phase
Remission of acute symptoms defines the beginning of the continuation phase, but relapse with full or partial return of symptoms is the most frequently encountered problem during the continuation phase. Successful acute therapies are therefore continued at full dosage for a period of time to prevent relapse. With the remission of symptoms, the continuation phase is also a time when denial of illness fosters noncompliance.

The length of the continuation phase is based on the clinician’s estimate of the period necessary to exceed the likely (natural) duration of the episode in the absence of treatment. Whether the estimated duration of the continuation phase is determined on the basis of the patient’s prior episodes or based on a more general estimate of the likely duration of depressive or manic episodes, the purpose of the continuation phase is to avoid relapse. This is most often accomplished by maintaining treatment at the levels required to induce remission, but it may involve titration of the dosage. Some treatment-responsive patients may benefit by dose reduction during the continuation phase if medication side effects substantially negate the gains due to remission of mood symptoms. A larger group will intermittently experience significant symptoms during the continuation phase (roughening), which, although they do not fulfill the criteria for an acute depressive episode, may warrant an increase in antidepressant (or antimanic) treatments.

The continuation phase ends and the discontinuation phase or maintenance phase begins when the patient is declared to have recovered from the acute episode.

Discontinuation Phase/Maintenance Phase
The discontinuation phase follows a decision to discontinue a treatment and involves monitoring for recurrence while gradually tapering medication.

A decision to redirect the therapeutic focus away from treatment of the acute episode toward maintaining recovery or preventing the recurrence of future acute episodes launches the maintenance phase. Many patients experience intermittent subsyndromal symptoms (roughening) during the discontinuation/maintenance phase. The significance of roughening depends on whether it is the harbinger of an impending acute episode or is merely a brief period of mild symptoms with little clear relation to the patient’s mood disorder. Studies of such interepisode symptoms done by Keller et al. (1992b) suggested that roughening with features of depression often resolves without intervention. Symptoms of hypomania carry a higher risk of evolving into full affective episodes.

The occurrence of symptoms meeting criteria for an acute episode would be considered a recurrence (new episode) requiring reintroduction of acute treatments.

How long should maintenance therapy continue? There is considerable debate as to when lifetime prophylaxis should be recommended. This complex debate need not impede most routine treatment, since in many important areas there is broad consensus among experts. Expert consensus supports at least 1 year of prophylaxis following the first manic episode and any subsequent manic episode. There is also general agreement that patients who have had three or more episodes should receive long-term maintenance therapy.