A 35-year-old man with a history of bipolar disorder since age 27 comes to the office for follow-up. The patient was hospitalized 2 years ago for a manic episode and was discharged with a therapeutic dose of lithium; he continues to take the same dose and is engaged in weekly psychotherapy. The patient says, "This is the best I've felt in years; work is going great, and I'm getting married in a few months. I really don't want to get hospitalized again, but I also don't want to keep taking medication if I don't have to." Prior medication trials include quetiapine and olanzapine with fluoxetine; both treatments were discontinued due to weight gain. Medical history is noncontributory. Vital signs and physical examination are unremarkable. The patient appears euthymic and has a full range of affect. Complete blood count, basic metabolic panel, and TSH are within normal limits; serum lithium level is within therapeutic range. Which of the following is the most appropriate response to this patient?

Question

A 35-year-old man with a history of bipolar disorder since age 27 comes to the office for follow-up.  The patient was hospitalized 2 years ago for a manic episode and was discharged with a therapeutic dose of lithium; he continues to take the same dose and is engaged in weekly psychotherapy.  The patient says, "This is the best I've felt in years; work is going great, and I'm getting married in a few months.  I really don't want to get hospitalized again, but I also don't want to keep taking medication if I don't have to."  Prior medication trials include quetiapine and olanzapine with fluoxetine; both treatments were discontinued due to weight gain.  Medical history is noncontributory.  Vital signs and physical examination are unremarkable.  The patient appears euthymic and has a full range of affect.  Complete blood count, basic metabolic panel, and TSH are within normal limits; serum lithium level is within therapeutic range.  Which of the following is the most appropriate response to this patient?

Quizplus · Accepted Answer

Bipolar disorder is a highly recurrent illness, and multiple mood episodes are typical. The goal of maintenance treatment is to decrease the risk for recurrent manic and depressive episodes that can severely impair functioning and relationships. Lithium is a first-line agent that has been studied extensively and helps decrease rates of relapse in patients with bipolar disorder. Discontinuing stable lithium treatment usually leads to a recurrent episode within months to a year and carries risks of hospitalization, economic losses, and suicide. Understanding the patient's reasons for not wanting to be on medication and responding to any specific concerns he has about lithium are important. However, treatment recommendations must take into account the high risk of recurrent episodes. This patient is doing well on a therapeutic dose of lithium (ie, no recurrent manic or depressive episodes since starting lithium 2 years ago) and is tolerating the medication without difficulty. His medication history indicates that other treatment options (ie, quetiapine, olanzapine with fluoxetine) resulted in unacceptable weight gain. The most appropriate response is to recommend continuing lithium at the same dose while monitoring for side effects. An analogy can be made to other chronic illnesses (eg, asthma) that may require prolonged medication usage. (Choice A) Because bipolar disorder is a highly recurrent illness, tapering off medication is not recommended. (Choice C) Lowering the dose of lithium is sometimes done to manage side effects. This patient's lithium dose is in the therapeutic range, and he is tolerating the medication without adverse effects; lowering the dose may result in a subtherapeutic dose and increase his risk for recurrence. (Choice D) Long-acting injectable antipsychotic agents (eg haloperidol, aripiprazole, risperidone) can be considered for maintenance treatment in bipolar disorder and can be especially useful for improving adherence. However, they are third-line agents typically used in patients who tolerated oral formulations. This patient is doing well on lithium, with a therapeutic blood level indicating adherence. Changing to a long-acting injectable is not indicated and may result in destabilization (eg, lag before reaching therapeutic levels) or be associated with side effects. Educational objective: Bipolar disorder is a highly recurrent illness. Maintenance treatment is recommended to decrease the risk of recurrent manic or depressive episodes. Lithium therapy should be maintained in patients whose condition is stable and who are tolerating the medication. References: Efficacy and safety of lithium and lamotrigine for the maintenance treatment of clinically stable patients with bipolar disorder: a systematic review and meta-analysis of double-blind, randomized, placebo-controlled trials with an enrichment design. (http://www.ncbi.nlm.nih.gov/pubmed/31026388) 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) Long term use of lithium and factors associated with treatment response among patients with bipolar disorder. (http://www.ncbi.nlm.nih.gov/pubmed/27287789)

A 35-Year-Old Man with a History of Bipolar Disorder Since