A 26-year-old man with bipolar I disorder comes to the office for a follow-up visit. He experienced his first manic episode 7 years ago and responded well to lithium. The patient became noncompliant with his medication after his condition improved and then experienced a second manic episode 9 months later. Over the next 5 years, he experienced 3 additional manic episodes, 2 depressive episodes, and a suicide attempt. Since his most recent hospitalization for a manic episode a year ago, he has remained on lithium and has had no depressive, manic, or hypomanic signs or symptoms. The patient also has no medication side effects, and lithium levels confirm that he is compliant. Today, he inquires about the possibility of discontinuing lithium as he has been very stable over the past year and prefers not to "be dependent on medication." There is a history of bipolar disorder in a maternal aunt. Which of the following is the most appropriate recommendation for this patient's condition?

Question

A 26-year-old man with bipolar I disorder comes to the office for a follow-up visit.  He experienced his first manic episode 7 years ago and responded well to lithium.  The patient became noncompliant with his medication after his condition improved and then experienced a second manic episode 9 months later.  Over the next 5 years, he experienced 3 additional manic episodes, 2 depressive episodes, and a suicide attempt.  Since his most recent hospitalization for a manic episode a year ago, he has remained on lithium and has had no depressive, manic, or hypomanic signs or symptoms.  The patient also has no medication side effects, and lithium levels confirm that he is compliant.  Today, he inquires about the possibility of discontinuing lithium as he has been very stable over the past year and prefers not to "be dependent on medication."  There is a history of bipolar disorder in a maternal aunt.  Which of the following is the most appropriate recommendation for this patient's condition?

Quizplus · Accepted Answer

Bipolar I disorder is a mood disorder characterized by recurrent episodes of mania and major depression. It is a lifelong illness that requires maintenance pharmacotherapy to reduce the risk of recurrent mood episodes. Most patients require maintenance for many years, and lifelong maintenance is indicated for those with a severe course (eg, frequent episodes, suicide attempts, severe symptoms, hospitalization). This patient has had 7 mood episodes already, including a suicide attempt, and has shown good response and tolerability to lithium. He should be strongly encouraged to remain on lithium as discontinuing stable treatment usually leads to a new mood episode within a year. In addition, maintenance treatment with lithium has consistently demonstrated a reduced suicide risk in bipolar patients. Patients often struggle with the idea of taking medication for their entire lives. A strong therapeutic alliance, psychoeducation, and adjunctive psychotherapy can help the patient accept the chronic nature of the illness and enhance adherence. If this patient insists on stopping lithium, the first step would be to try to cross-taper to another antimanic agent (eg, valproate, lamotrigine, quetiapine). If the patient refuses all pharmacotherapy, lithium should be slowly tapered over weeks to months and frequently monitored to identify early signs and symptoms of recurrence. (Choices B and D) Because lithium has been effective and well tolerated in this patient, it should not be discontinued at this time. If this patient were a candidate for a trial off medication, a gradual discontinuation (over several months) would be recommended to help delay recurrence. Discontinuing lithium quickly poses a high risk for relapse and even suicide. (Choice C) Although psychotherapy is an important adjunctive treatment, it should be combined with medication to reduce the risk of relapse. (Choice E) This patient is stable and tolerating lithium without side effects; therefore, switching to valproate is not indicated. (Choice F) Continuing treatment for an additional year with subsequent discontinuation is contraindicated in this patient and would likely result in relapse. In the absence of significant side effects or contraindications, long-term maintenance therapy should be recommended to this patient. Educational objective: Bipolar I disorder is a highly recurrent illness that requires long-term maintenance pharmacotherapy to decrease the risk of recurrent mood episodes. Clinically effective medication should be continued unless significant side effects or contraindications prohibit use. References: Maintenance therapies in bipolar disorders. (http://www.ncbi.nlm.nih.gov/pubmed/22510036) Comparative efficacy and tolerability of pharmacological treatments in the maintenance treatment of bipolar disorder: a systematic review and network meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/26360999)

A 26-Year-Old Man with Bipolar I Disorder Comes to the Office