• Patients should avoid anti-anxiety drugs, alcohol, caffeine, and stimulants.
• Patients should avoid exposure to bright light.
• All efforts should be made to help the patient sleep normally.

Treatment Guidelines for Maintenance

Drugs Used During Maintenance. Relapse occurs in most patients after treatment of acute attacks, and patients who are at high risk for recurring episodes should consider life-long maintenance therapy. This usually involves mood-stabilizing drugs:

• Lithium is a first-line mood stabilizer used in maintenance therapy. The anti-epileptic drug valproate is also a first-line treatment. In general, the two work equally well, although there are some differences in side effects.
• Lamotrigine, another anti-epileptic drug, is approved as a maintenance treatment for bipolar I disorder and may also be used as a first-line drug for treating depressive episodes.
• Carbamazepine and oxcarbazepine are other anti-epileptic drugs used as alternative maintenance treatments.
• Atypical antipsychotics may be used for maintenance, particularly in combination with a mood stabilizer.

The general recommendations for maintenance therapy with lithium are as follows:

• The earlier lithium is started in the disease process, the better. Studies suggest that patients on long-term lithium therapy have survival rates comparable to the general population, but those who permanently drop out of therapy have significantly lower survival rates due to an increased suicide risk.
• Patients who stop lithium and then start again may be at higher risk for hospitalization and are more likely to need more than one drug.
• For those who want to stop, a gradual discontinuation (over 15 - 30 days) may help to delay recurrence. Stopping lithium quickly poses a high risk for relapse and for suicide.

Treatment Guidelines for Pregnant Patients with Bipolar Disorder

Treatment of pregnant women with bipolar disorder poses specific challenges. All psychiatric medications can cross the placenta into amniotic fluid. These drugs can also enter breast milk. While certain types of medications present more risks to the fetus than others, not taking medications also carries substantial risks. Untreated women may be less likely to receive appropriate prenatal care, and more likely to engage in risky behaviors, including alcohol and tobacco use. Non-treatment may also cause difficulties with mother-infant bonding and disruptions in the family environment.

Before conceiving, a woman with bipolar disorder should consult with her obstetrician, psychiatrist, and primary care physician. Close follow-up with all of these providers should take place during the pregnancy.

The American College of Obstetricians and Gynecologists (ACOG) has guidelines for psychiatric drug treatment during pregnancy:

• When possible, a single medication at a higher dosage is preferred over multiple medications.
• Lithium is associated with a small increased risk for heart defects and other birth defects in the fetus.
• For a pregnant woman with mild bipolar disorder, the medication may be gradually tapered off before conception. Women who are at moderate risk for relapse are often asked to stop taking lithium until the fetus’ organ formation is complete. Women at high risk for bipolar disorder relapse may need to continue taking lithium throughout the pregnancy.
• Women should have their lithium levels closely monitored during pregnancy. Lithium levels in the blood that were previously stable may change during pregnancy.
• If lithium was taken during the first trimester, ultrasound and perhaps echocardiography are generally performed to evaluate the fetal heart.
• Women who must take lithium during pregnancy should take the lowest possible dosage and stop the drug 1 - 2 days before delivery. Mothers who are taking lithium should not nurse their babies, since lithium is concentrated in breast milk.

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Review Date: 01/28/2011
Reviewed By: Harvey Simon, MD, Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.

A.D.A.M., Inc. is accredited by URAC, also known as the American Accreditation HealthCare Commission (www.urac.org)