Clinical Guideline to Treatment during the Maintenance Phase for Bipolar Disorder
| 1st step | • Start with lithium, aripiprazole, olanzapine, paliperidone, quetiapine, or risperidone (including RLAI) monotherapy • Consider CBT or psychoeducation as add-on to medication. Never consider CBT or psychoeducation as monotherapy • Take predominant polarity (if present) into consideration |
| 2nd step | • Add fluoxetine or lithium on the first-step option • Lithium plus carbamazepine • Quetiapine plus lithium or valproate • Olanzapine or aripiprazole plus a mood stabilizer |
| 3rd step | Add RLAI, valproate, carbamazepine, lamotrigine, or N-acetylcysteine on second-step treatment |
| 4th step | Take into consideration the predominant polarity and add an agent with proven efficacy against the acute phase no matter whether it has proven maintenance efficacy. Consider adding venlafaxine or haloperidol |
| 5th step | Consider any combinations from steps 1–4 that have not been tried Consider maintenance ECT Various combinations of medication according to anecdotal knowledge or the personal experience of the therapist |
| Not recommended | Adding memantine or perphenazine on a mood stabilizer, aripiprazole plus lamotrigine or valproate, lamotrigine plus valproate, lithium plus lamotrigine, imipramine, or oxcarbazepine. |
| 1st step | • Start with lithium, aripiprazole, olanzapine, paliperidone, quetiapine, or risperidone (including RLAI) monotherapy • Consider CBT or psychoeducation as add-on to medication. Never consider CBT or psychoeducation as monotherapy • Take predominant polarity (if present) into consideration |
| 2nd step | • Add fluoxetine or lithium on the first-step option • Lithium plus carbamazepine • Quetiapine plus lithium or valproate • Olanzapine or aripiprazole plus a mood stabilizer |
| 3rd step | Add RLAI, valproate, carbamazepine, lamotrigine, or N-acetylcysteine on second-step treatment |
| 4th step | Take into consideration the predominant polarity and add an agent with proven efficacy against the acute phase no matter whether it has proven maintenance efficacy. Consider adding venlafaxine or haloperidol |
| 5th step | Consider any combinations from steps 1–4 that have not been tried Consider maintenance ECT Various combinations of medication according to anecdotal knowledge or the personal experience of the therapist |
| Not recommended | Adding memantine or perphenazine on a mood stabilizer, aripiprazole plus lamotrigine or valproate, lamotrigine plus valproate, lithium plus lamotrigine, imipramine, or oxcarbazepine. |
Abbreviations: ECT, electroconvulsive therapy; RLAI, risperidone long acting injectable.
Clinical Guideline to Treatment during the Maintenance Phase for Bipolar Disorder
| 1st step | • Start with lithium, aripiprazole, olanzapine, paliperidone, quetiapine, or risperidone (including RLAI) monotherapy • Consider CBT or psychoeducation as add-on to medication. Never consider CBT or psychoeducation as monotherapy • Take predominant polarity (if present) into consideration |
| 2nd step | • Add fluoxetine or lithium on the first-step option • Lithium plus carbamazepine • Quetiapine plus lithium or valproate • Olanzapine or aripiprazole plus a mood stabilizer |
| 3rd step | Add RLAI, valproate, carbamazepine, lamotrigine, or N-acetylcysteine on second-step treatment |
| 4th step | Take into consideration the predominant polarity and add an agent with proven efficacy against the acute phase no matter whether it has proven maintenance efficacy. Consider adding venlafaxine or haloperidol |
| 5th step | Consider any combinations from steps 1–4 that have not been tried Consider maintenance ECT Various combinations of medication according to anecdotal knowledge or the personal experience of the therapist |
| Not recommended | Adding memantine or perphenazine on a mood stabilizer, aripiprazole plus lamotrigine or valproate, lamotrigine plus valproate, lithium plus lamotrigine, imipramine, or oxcarbazepine. |
| 1st step | • Start with lithium, aripiprazole, olanzapine, paliperidone, quetiapine, or risperidone (including RLAI) monotherapy • Consider CBT or psychoeducation as add-on to medication. Never consider CBT or psychoeducation as monotherapy • Take predominant polarity (if present) into consideration |
| 2nd step | • Add fluoxetine or lithium on the first-step option • Lithium plus carbamazepine • Quetiapine plus lithium or valproate • Olanzapine or aripiprazole plus a mood stabilizer |
| 3rd step | Add RLAI, valproate, carbamazepine, lamotrigine, or N-acetylcysteine on second-step treatment |
| 4th step | Take into consideration the predominant polarity and add an agent with proven efficacy against the acute phase no matter whether it has proven maintenance efficacy. Consider adding venlafaxine or haloperidol |
| 5th step | Consider any combinations from steps 1–4 that have not been tried Consider maintenance ECT Various combinations of medication according to anecdotal knowledge or the personal experience of the therapist |
| Not recommended | Adding memantine or perphenazine on a mood stabilizer, aripiprazole plus lamotrigine or valproate, lamotrigine plus valproate, lithium plus lamotrigine, imipramine, or oxcarbazepine. |
Abbreviations: ECT, electroconvulsive therapy; RLAI, risperidone long acting injectable.
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