Is Lithium Still the Maintenance Treatment of Choice for Bipolar Disorder?
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- Silverstone, T. Mol Diag Ther (2000) 14: 81. doi:10.2165/00023210-200014020-00001
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For over 25 years lithium was regarded as the drug of choice for prophylactic treatment in patients with bipolar disorder. More recently its place in the long term management of this condition has been questioned. A number of long term naturalistic studies have revealed that lithium is less effective in clinical practice than would be anticipated from clinical trial data. A major factor contributing to this discrepancy is the poor adherence to medication shown by over a third of patients taking the drug long term. Another possible reason is a broadening of the diagnostic criteria for bipolar disorder to include patients with mood-incongruent psychotic symptoms and/or comorbid substance abuse.
Following initially favourable reports from open studies, the anticonvulsant compounds carbamazepine and valproic acid (sodium valproate) have come to be widely used in the long term management of bipolar disorder. However, there is, thus far, little confirmatory evidence from controlled clinical trials to support this practice. The same is true for the use of the newer atypical antipsychotics and the newer anticonvulsants in the treatment of bipolar disorder. Until there is convincing evidence from controlled clinical trials that these alternatives are superior to lithium in improving the overall well-being of patients with bipolar disorder, it is my opinion that lithium remains the drug of choice.