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Maintaining mood stability in bipolar disorder: a clinical perspective on pharmacotherapy
  1. Gin S Malhi1,2,
  2. Claire McAulay1,2,
  3. Pritha Das1,2,
  4. Kristina Fritz1,2
  1. 1Discipline of Psychiatry, Sydney Medical School, University of Sydney, St Leonards, New South Wales, Australia
  2. 2Department of Psychiatry, CADE Clinic, Royal North Shore Hospital, St Leonards, New South Wales, Australia
  1. Correspondence to Professor Gin S Malhi; gin.malhi{at}

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Bipolar disorder is defined by its poles, elevated mood or irritability characterises mania, and marked low mood and lack of energy typifies depression. Treatment of these acute states is necessary for the patient's well-being but the major management challenge lies in reducing the frequency and severity of relapses and recurrences, and maintaining healthy mood. Typically, patients with bipolar disorder experience a recurrence every 17–30 months and have multiple episodes over the course of the illness.1 Successful management of this chronic, recurrent illness ultimately depends on maintaining long-term mood stability and preventing further episodes of depression and mania. It is therefore, all the more remarkable that maintenance therapies have received sparse attention; this is partly because longitudinal research is difficult to design and conduct. Therefore, clinicians often have to draw on experience regarding the long-term use of medications. This paper outlines the options for long-term pharmacotherapy of bipolar disorder and addresses common clinical questions regarding administration, drawing on a synthesis of current evidence for maintenance agents.


To identify relevant evidence for the long-term pharmacological management of bipolar disorder electronic database searches were conducted using Summon (the University of Sydney's cross-search engine), OvidSP (including PubMed and PsycINFO) and Cochrane reviews. Searches were limited to the past 7 years. In addition existing systematic reviews were carefully scrutinised and their bibliographies drawn on to identify additional studies of note which were appraised alongside recent clinical trials. This review primarily included studies that were randomised, placebo-controlled, blinded, non-enriched and of sufficient duration to be regarded as maintenance therapy. Studies that did not meet all these principal requirements, such as those with external validity in non-randomised settings, were also reviewed cautiously and their findings were considered with limitations. Their impact in determining treatment decisions was moderated accordingly. The need to institute this process reflects the paucity of …

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