Pharmacological interventions for the prevention of relapse in bipolar disorder: a systematic review of controlled trials

Abstract

We conducted a systematic review and meta-analysis of randomised and quasi-randomised controlled trials evaluating all clinically relevant pharmacological interventions for the prevention of relapse in people with bipolar disorder. Thirty-four trials were included in the review. Direct comparisons with placebo and with lithium were available for most drugs. In addition, there were direct comparisons of valproate vs. olanzapine, imipramine vs. lithium plus imipramine, olanzapine plus mood stabilisers vs. mood stabilisers and perphenazine plus mood stabilisers vs. mood stabilisers. Methodological quality varied across studies and the strength of evidence was not equal for all treatments or for all comparisons. There is evidence from placebo-controlled trials for the efficacy of lithium, valproate and lamotrigine as maintenance therapy for the prevention of relapse in bipolar disorder. Three drugs have a significant effect in the prevention of manic relapses (lithium, olanzapine and aripiprazole) and three in the prevention of depressive symptoms (valproate, lamotrigine and imipramine). Imipramine is little used in practice, because of concern about adverse effects. The significant effects of olanzapine and aripiprazole were demonstrated in selected responsive bipolar I patients only. Despite widespread use in clinical practice, there is little evidence to support the efficacy of combination therapy.

Current prescription pattern of maintenance treatments for bipolar patients in Korea: A focus on the transition from acute treatments

“…However, a recent systematic review still concluded that there was little evidence to support the efficacy of combination therapy despite its widespread use in Korean clinical practice. 7 Among types of MS, more clinical evidence (level A, full evidence from controlled studies) supports the use of lithium than that of valproate (level C, evidence from uncontrolled studies) in terms of efficacy in an enriched sample. 8 The Bipolar Affective Disorder: Lithium/Anticonvulsant Evaluation (BALANCE) study also showed that valproate monotherapy may have a lesser effect in preventing relapse rather than lithium + valproate and lithium monotherapy.…”

“…They were nearly all of the BP patients who had achieved clinical remission during the last 6 months and who had their medical records in the sites. Patients' prior episodes were identified as manic (199, 58.5%), hypomanic (33, 9.7%), mixed (25,7.4%), and depressive (70, 20.6%) ( Table 1).…”

Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) collaborative update of CANMAT guidelines for the management of patients with bipolar disorder: update 2013

“…A systematic review of pharmacological interventions for the prevention of relapse in BD included 34 RCTs and quasi-RCTs, and concluded that lithium, olanzapine, and aripiprazole had significant effects in the prevention of manic relapses, as did divalproex, lamotrigine, and imipramine in the prevention of depressive symptoms (161). A meta-analysis of 20 RCTs (n = 5364) assessing the relative risk for relapse in patients with BD in remission confirmed the efficacy of lithium, divalproex, lamotrigine, and a number of atypical antipsychotic agents in preventing relapse to any episode versus placebo (162).…”

Bipolar disorder in Turkey: A review

“…Son yıllarda gerek Avrupa gerekse Amerika'da yeniden değerinin iade edilmeye çalışıl-dığı lityum ülkemizde en yaygın kullanılan duygudurum dengeleyicidir. [63] Duygudurum dengeleyici bir diğer antikonvulzan olan lamotrijin sadece depresif atakta %5'i aşan bir kullanım sergilemektedir. Çok uzun olmayan bir süre öncesine dek yaygın olarak kullandığımız karbamazepinin, her bir duygudurum döneminde ve iyilikte kullanımı, bu çalışmada çok çarpıcı bir şekilde gördüğümüz üzere %3'ü geçmemektedir.…”