From the Research
The next step in treatment for a patient with rapid cycling bipolar disorder not responding well to valproate would be to add lithium or switch to lithium monotherapy, as supported by the most recent and highest quality study 1. This approach is based on the fact that rapid cycling often represents a more treatment-resistant form of bipolar disorder, and lithium has mood-stabilizing properties that work through different mechanisms than valproate, potentially providing complementary effects. Some key points to consider when initiating lithium therapy include:
- Starting with a low dose (300mg twice daily) and titrating gradually while monitoring serum levels (target 0.8-1.0 mEq/L for acute treatment, 0.6-0.8 mEq/L for maintenance) 1
- Regular monitoring of thyroid function, renal function, and electrolytes is essential with lithium therapy 1
- Combination therapy with valproate plus lithium may be particularly effective for rapid cycling patients who have partial response to monotherapy 2 If the patient has already tried lithium or has contraindications to its use, alternative options include adding or switching to a second-generation antipsychotic such as quetiapine, olanzapine, or aripiprazole, as supported by studies 2, 3. Additionally, psychotherapy such as cognitive behavioral therapy or interpersonal and social rhythm therapy may provide additional benefit for patients who continue to experience breakthrough episodes despite optimized pharmacotherapy 4.