Maintenance treatment

Maintenance treatment means treatment continuing after an acute episode of mania or depression has passed. The main goal of maintenance treatment  is simple; avoiding recurrence of further episodes of mania and depression and also minimising ‘sub syndromal’ symptoms of depression which may impair life quality and functioning but do not fully meet criteria for a depressive episode.

Some people are lucky after a manic episode and never have another one. The same is true of people who suffer a depressive episode and who have a history of hypomania, but statistically the probablity of being ‘lucky’ is much less than being unlucky and the potential disruption from a further severe episode of illness is considerable. Also the probablity of being able to prevent or delay this with good treatment and also to minimise troublesome subsyndromal depressive symptoms is high.

These are facts and it often difficult to hear and come to terms with them. The ‘art’ of  good treatment of bipolar disorder is finding a combination of approaches which works for you with a minimum of side-effects and working closely to establish a good realtionship with a professional to achieve this goal. It also involves learning ‘self management’ approaches to pick up early signs of any recurrence of symptoms and techniques which can help deal with them along side medication and formal ‘talking therapies’.

Perhaps the most important thing to remember is to keep an open mind as to the options available for your treatment and remember that you are an individual who deserves careful explanation of a maintence/ relapse prevention plan.

It is also important to acknowledge that even with all the knowledge of risk of recurrence there can be times when an individual will make an informed decision after having been on maintenance medication for sometime that they really want to take the risk and see if they can manage without medication. From a lot of experience the most important things in this situation here are:

  1. To pick a good time when the knock on effects of any recurrence of symptoms would be as little as possible
  2. To inform and involve a healthcare professional in monitoring things with you a bit more closely during the time you are coming off medication and for the period afterwards and
  3. To make the transition off medication as gradual as possible as we know that sudden cessation of medication increases the risk of relapse.

Remember however, many people with bipolar disorder do extremely well on maintenance medication with minimal or no side effects. If you needed to be on maintenance treatment for diabetes or arthritis you wouldn’t be excited about it, but you would probably accept you had to take it.

 

A Summary From
Relapse Prevention and Bipolar Disorder: A Focus on Bipolar Depression, Mark Hyman Rapaport, M.D. and Deborah J. Hales, M.D. Focus 1:15-31 (2003)
“How psychiatrists manage bipolar disorder has evolved as longitudinal data have been published and new therapies have been developed. Most clinicians now believe that a substantial number of our patients with bipolar disorder require longer-term, if not indefinite, treatment. There has been a progression in the development of the nosology and the treatment recommendations for bipolar disorder, similar to what has occurred with major depressive disorder. The initial treatment guidelines for bipolar disorder distinguished between the continuation and maintenance phases of treatment in a way that was analogous to the recommendations for major depressive disorder (13). However, the American Psychiatric Association (APA) Practice Guideline for the Treatment of Patients With Bipolar Disorder (Revision) stated that this may be an artificial distinction for patients with bipolar disorder (14). The current guidelines suggest that the acute phase extends through the first 6 months of stabilization, and that the maintenance phase extends from that point forward. The most recent APA Practice Guideline recommends initiating maintenance therapy for all patients who have experienced a manic episode (14).

Long-term treatment strategies for bipolar II first were discussed in the 1996 Expert Consensus Guidelines, and these guidelines recommend that long-term, if not lifelong, therapy with a mood stabilizer be considered for individuals who have suffered three or more hypomanic episodes (13). A lower threshold for long-term treatment (e.g., one or two hypomanic episodes) was suggested for patients with a strong family history. Consensus about the need for long-term treatment of bipolar II disorders is still developing. Sachs and colleagues published recommendations that long-term treatment with a mood stabilizer be considered, irrespective of number of episodes, for bipolar II patients with the following:

  1. antidepressant-induced mania or hypomania,
  2. severe spontaneous hypomanic episodes,
  3. frequent and severe depressions,
  4. a strong family history of mania, and
  5. a current need for antidepressant treatment (15).

The most recent recommendations from the APA Practice Guideline suggest that maintenance therapy is “strongly warranted” for patients with bipolar II disorder but acknowledge the need for more research in this area (14).”