Beyond the Guidelines for Bipolar Disorder: Practical Issues in Long-Term Treatment With Lithium

Objective: Several treatment guidelines are available for clinicians working with patients with bipolar disorder (BD), but some of the more nuanced aspects of lithium therapy go beyond the scope of such guidelines. Therefore, in this perspective, our objective was to focus on specific practical issues of lithium treatment, including the selection and initiation of long-term treatment, and management and discontinuation (if indicated) of lithium prophylaxis. Method: We conducted a focused review of the relevant literature on the treatment of BD. Results: Consultation requests to a BD specialty service often relate to issues for which there is limited evidence, including when to initiate long-term treatment, whether choice of mood stabilizer is specific, how long to treat acute episodes, whether to switch or add on medication when treatment fails, how long to continue effective treatment, and what medication to use when a lithium-responsive patient must discontinue lithium. Conclusion: Optimal long-term treatment of BD will require more research as well as better alignment of clinical and training programs.