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Bipolar disorders: from remission to maintenance

The management of bipolar disorder has traditionally focused upon the treatment of acute mania and although this is a fundamental aspect of patients' care, other aspects of mood stabilisation, e.g. treatment of depression, have been overshadowed. Most of the problems come when decisions are based only on the potential efficacy of treatments, rather than effectiveness. Efficacy responds to the question: Does a treatment work under ideal conditions?, whereas effectiveness responds to the question: Does a treatment work under the conditions of routine care?. The answer to the second question should be more relevant to clinicians. Moreover, in the past decade we have learned that beyond improvement and short-term response, we have to design our therapies to achieve remission and maintain it successfully, which means recovery.

Indeed, the mood-stabilising agent lithium, introduced in 1949 as a treatment for mania is the mainstay of long-term treatment of bipolar disorder and is in widespread clinical use. However, lithium has a slow onset of action and is not very well tolerated, so despite its efficacy, effectiveness is quite low. Of those patients with bipolar disorder who receive treatment, poor adherence with medication is a significant problem. When associated with lithium treatment in particular, poor adherence increases the risk of relapse. The need for well-tolerated agents with efficacy in depression as well as mania, has led researchers to evaluate the potential of a variety of anticonvulsants, antidepressants and antipsychotics as primary or adjunctive, which have proved to be efficacious and generally safer than the older drugs. Besides lithium and traditional anticonvulsants, the atypical antipsychotics, novel anticonvulsants, and psychoeducational approaches are effective new tools for the treatment of bipolar illness. All them should be reasonably combined in treatment regimens aimed at achieving not only remission of acute episodes, but long-term recovery.

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Open Access This article is published under license to BioMed Central Ltd. This is an Open Access article is distributed under the terms of the Creative Commons Attribution 2.0 International License (, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Vieta, E. Bipolar disorders: from remission to maintenance. Ann Gen Psychiatry 5 (Suppl 1), S26 (2006).

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