Harvard Mental Health Letter

In Brief: Preventing relapse in bipolar disorder

An international study has concluded that lithium alone, or the combination of lithium and valproate (Depakote), is more effective than valproate alone in preventing relapse in patients with bipolar disorder. At the same time, however, the study provides a reminder that relapse is common in such patients, even when they take medication regularly.

Investigators launched the Bipolar Affective Disorder: Lithium/Anticonvulsant Evaluation (BALANCE) trial in part because prescription patterns have changed so dramatically since 2000. Lithium was once the only option available to patients with bipolar disorder, and is still considered the best agent for reducing risk of suicide. Although effective, lithium can damage the kidneys. When lithium levels in a patient's blood exceed a narrow therapeutic window, this drug can also have other toxic effects.

Current practice guidelines recommend valproate as an alternative first-line treatment for long-term maintenance therapy. Partly as a result, prescription patterns have changed. In the United States, for example, lithium prescriptions dropped by about 40% in the 1990s, while valproate prescriptions rose by 250%.

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