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Medication for relapse prevention

How are medications related to relapse?

Bipolar disorder is a disabling condition characterised by episodes of mania or hypomania and depression. Adherence to pharmacological treatment is critical for effective control of symptoms and to prevent relapse.

What is the evidence for pharmaceutical treatments for relapse prevention?

Overall, moderate to high quality evidence finds maintaining antipsychotic or mood stabiliser treatment is associated with fewer relapses than discontinuing antipsychotic or mood stabiliser treatment.

Medications compared to placebo

Moderate quality evidence finds the following medications reduced overall relapse rates more than placebo (in descending order of effectiveness); asenapine, aripiprazole + valproate, lithium + oxcarbazepine, olanzapine, aripiprazole once monthly, lithium + valproate, quetiapine, aripiprazole + lamotrigine, aripiprazole, lithium, valproate, risperidone long-acting injectable, and lamotrigine. Carbamazepine and paliperidone performed no better than placebo.

Compared to placebo plus mood stabilisers, there were fewer relapses after six months of treatment with second-generation antipsychotics plus mood stabilisers (mostly lithium or valproate). Aripiprazole + mood stabilisers and quetiapine + mood stabilisers prevented both depression and mania relapses, while lurasidone + mood stabilisers was more effective for preventing relapse to depression, and ziprasidone + mood stabilisers was more effective for preventing relapse to mania.

For side effects, moderate to low quality evidence finds placebo was better tolerated than carbamazepine, lithium, or lithium + valproate. There was greater incidence of prolactin-related adverse events with long-acting injectable risperidone, more weight gain with olanzapine, risperidone, quetiapine and aripiprazole, more tremor with aripiprazole and risperidone, more restlessness with aripiprazole, and more sedation with olanzapine and quetiapine.

Medications compared to other medications

There were fewer relapses with olanzapine than with imipramine, paliperidone, or lamotrigine; fewer relapses with quetiapine than with imipramine or lamotrigine; fewer relapses with lithium or lithium + valproate than with imipramine; and fewer relapses with aripiprazole + valproate than with imipramine or paliperidone. There were fewer relapses, particularly to mania, with long-acting injectable risperidone or flupenthixol decanoate than with any oral medication.

For side effects, moderate to low quality evidence finds lamotrigine was better tolerated than carbamazepine, lithium, or lithium + valproate. Long-acting injectable risperidone was associated with more prolactin-related adverse events than any oral medications.

November 2021

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Last updated at: 5:38 pm, 15th February 2022
To view documentation related to this topic download the files below
Fact Sheet Technical Commentary
Tags:  Relapse

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