After ten years of successful maintenance treatment with lithium and olanzapine, a 40-year-old woman with bipolar disorder expressed concerns about continuing the use of medicines, as she was planning a pregnancy. In the past, she had suffered from five severe manic episodes with hospital admissions. After consultations with the treating psychiatrist, gynaecologist, and family doctor, olanzapine was stopped and lithium was gradually withdrawn. After few months, the patient, still in treatment with lithium 300 mg/die, experienced a new manic episode with hospital admission. Treatment with lithium and olanzapine was restored, and she progressively recovered. This case suggests that the risk of manic recurrence after ten years of maintenance treatment may be as high as the well-known risk of recurrence after few years of maintenance treatment, a consideration that doctors may find useful in the light of a complete absence of evidence on treatment choices after five years of successful maintenance treatment.
This case highlights concerns around treatment choices in women with bipolar disorder seeking pregnancy [
In March 2012, a 40-year-old woman with a long history of bipolar disorder discussed with the treating psychiatrist the possibility of planning a pregnancy. The patient had been free of manic episodes for ten years. She was on maintenance treatment with lithium 1,200 mg/die and olanzapine 2.5 mg/die and was worried about the potential teratogenic effects of lithium as well as the potential adverse effects of olanzapine during pregnancy.
In the past, she had suffered from five severe manic episodes that had always led to hospital admission (Figure
Psychiatric history of a 40-year-old woman with bipolar disorder. The gray box indicates hospital admission, and the white box indicates the length of pharmacological treatment.
In terms of drug treatments, during the first two episodes, she was given haloperidol and benzodiazepines, and on discharge after the second admission, drug treatment was withdrawn as a result of a shared decision-making process (Figure
After initial talks with the treating psychiatrist about the possibility of actively seeking a pregnancy, during 2012, the patient had consultations with the treating gynaecologist and family doctor, who gave advice on pros and cons of stopping versus continuing drug treatment. Subsequent discussions involved the patient’s partner, who had never seen the patient during a manic phase and was in favour of stopping all medicines. A decision was finally taken of stopping olanzapine and gradually withdrawing lithium, decreasing 150 mg every 15 days. Agreement was reached to keep weekly contacts with the treating psychiatrist.
The patient remained well until February 2013 when, still in treatment with lithium 300 mg/die, during a holiday in Rome, she started making phone calls to the treating psychiatrist, and the phone talks revealed that she was experiencing mood elevation, a progressive decreased need for sleep, marked distractibility, and increased energy and activity. Contact with reality did not appear to be lost. The patient’s partner was advised to increase lithium and to take the patient back to Verona, where she was admitted to hospital, as it was impossible to manage this new manic episode in community. The patient spent more than two months in hospital and became psychotic, very aggressive, and agitated. Lithium was restored at 1,200 mg/die and olanzapine at 20 mg/die. At discharge, full recovery was achieved, although she felt sedated and mentally slowed down. Full-illness insight was rapidly restored.
This case highlights the general clinical problem of the length of drug treatment in patients with bipolar disorder, who have been stable on maintenance therapy for several years, when valid reasons for discontinuation existed. The NICE guidelines recommend to continue treatment for up to five years if the person has risk factors for relapse, such as a history of frequent relapses or severe psychotic episodes [
This case has implications for practicing doctors. First, we suggest that the risk of manic recurrence after ten years of maintenance treatment may be as high as the risk of recurrence after few years of maintenance treatment. Evidence exists suggesting that after an average length of 30 months of lithium maintenance treatment, the risk of manic episode following discontinuation translates into a 28-fold difference for patients on and just off lithium [
In terms of research priorities, we argue that studies should gently switch from current strong focus on short-term outcomes in acutely ill patients to the more challenging issue of treatment choices in individuals exposed to psychotropic drugs in the long term.