Treatments 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?

Medications compared to placebo

Moderate to high quality evidence suggests fewer relapses to mania with risperidone, olanzapine, and quetiapine. Lower quality evidence suggests fewer relapses to mania with aripiprazole. There were fewer relapses to depression with olanzapine and quetiapine, but not with risperidone or aripiprazole. Moderate quality evidence suggests fewer relapses in general with lithium, lamotrigine, valproate, lithium plus imipramine, lithium plus oxcarbazepine, lithium plus valproate, lamotrigine plus aripiprazole, and valproate plus aripiprazole.

For side effects, 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. Placebo was better tolerated in general than carbamazepine, lithium, or lithium + valproate.

Medications compared to other medications

Moderate to high quality evidence suggests fewer relapses to mania or depression with quetiapine plus lithium or valproate compared to placebo plus lithium or valproate. Quetiapine without adjunctive lithium or valproate was only effective for preventing relapse to mania. Moderate to low quality evidence suggests fewer relapses to mania with aripiprazole or risperidone plus lithium or valproate compared to placebo plus lithium or valproate, and fewer relapses in general with olanzapine or ziprazidone plus lithium or valproate.

Moderate to low quality evidence suggests 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 plus valproate than with imipramine; fewer relapses with aripiprazole plus valproate than with imipramine or paliperidone; and fewer relapses, particularly to mania, with long-acting injectable risperidone or flupenthixol decanoate than with any oral medication.
For side effects, lamotrigine was better tolerated than carbamazepine, lithium, or lithium plus valproate, and long-acting injectable risperidone was associated with more prolactin-related adverse events than any oral medication.

April 2019

Last updated at: 1:45 am, 2nd April 2019
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