Hamlet’s augury: how to manage discontinuation of mood stabilizers in bipolar disorder

Abstract

Research has generated good quality evidence about the treatment and management of bipolar disorder in acute and, to some degree, sub-acute/continuation phases. This has informed various guidelines about the treatment and management of bipolar disorder (BD). However, for the long-term or maintenance phase of illness, most guidelines peter out and, in the absence of sufficiently high-quality research evidence, remain vague. This is particularly evident for the important clinical question of discontinuing mood stabilizing pharmacological agents after a period of remission has been achieved. The aim of this review is to put together current existing evidence about discontinuing mood stabilizers after a period of remission in order to come up with a structured and coherent strategy for managing such discontinuation and to make recommendations for future research. To this end, we reviewed the main relevant treatment guidelines and subsequent evidence following the publication of these guidelines. The current recommended long-term treatment of BD is usually considered within the same principles applicable to any chronic health condition (e.g. hypertension or diabetes) where the focus is on continuing treatment at minimum effective medication dose often life-long, switching to alternative choice of medication due to side-effects and very few, if any, indications for complete cessation. However, in the absence of strong evidence on long-term treatment and the high rate of non-concordance in BD, medication discontinuation is a very important aspect of the treatment that should be given due consideration at every aspect of the treatment.

Manic Episodes in a Patient With Neurosyphilis Following Brief Discontinuation of Bipolar Medication

“…As seen in our patient, abrupt discontinuation of both lithium and valproic acid can result in a relapse of bipolar disorder [ 16 ]. Generally, the dose of lithium and valproic acid should be gradually tapered off over several weeks to minimize the risk of withdrawal symptoms or relapse [ 16 , 17 ]. Due to this patient's acute kidney injury, hyperammonemia, and elevated liver enzymes, both lithium and valproic acid were discontinued over a very short period, likely contributing to the relapse of his bipolar symptoms.…”