Mohammed T. Abou-Saleh

LONG-TERM MANAGEMENT 455DEPRESSIONMANIAFirst episodeRecurrentBipolarFirst episodeRecovered onantidepressants± ECTContinueantidepressantsfor six monthsafter fullremissionUnipolarRecovered onantidepressants± ECTOptionRecovered onlithium± neurolepticsWithdrawneurolepticsProphylacticlithiumRecovered onlithium± neurolepticsWithdrawneurolepticsContinue lithiumfor 3–6 monthsProphylacticantidepressantsProphylacticlithiumRelapse/recurrenceRelapse/recurrenceRelapse/recurrenceDepressionManiaOptionECTOptionOptionOptionAddlithiumAddantidepressantAddcarbamazepineAddneurolepticsFailFail? Withdrawantidepressant? WithdrawlithiumStopcarbamazepineStopneurolepticsECTFigure 80.1Long-term management of depression and maniadepression with melancholia and in depression with psychoticfeatures (delusional depression), which are particularly commonamong the elderly, with a tendency to respond less well toantidepressants 17 . The other advantage of lithium therapy is theevident decreased mortality, whether from suicide or othercauses 27 . A recent 1 year prospective, placebo-controlled studyof maintenance lithium in conjunction with CBT in elderlydepressed patients 28 showed that, although CBT reduced depressionseverity during follow-up, lithium therapy was no better thanplacebo. This appears to be related to poor compliance, a findingthat highlights the serious difficulties in undertaking prophylacticstudies in elderly depressed patients.Lithium TherapyThe use of lithium in the management of affective disorders hasproved to be one of the most rewarding therapeutic strategies inmedical practice. In the management of bipolar disorders, it hasprovided one of the most specific psychotropic drugs inpsychiatry. Lithium is the treatment of choice for mania andhas comparable efficacy to neuroleptics, except in disturbed andagitated manic patients, who respond more dramatically toneuroleptic medication. The advantage of lithium, however, isthat patients do not complain of the ‘‘strait-jacket’’ effect theyexperience with neuroleptics. Moreover, intermittent exposure toneuroleptics has been shown to be associated with a highincidence of tardive dyskinesia, particularly in the elderly, whoare often less tolerant of neuroleptics and more commonlydevelop parkinsonian side effects. Lithium is also stronglyrecommended for the treatment of bipolar depression, ratherthan tricyclics, which may provoke hypomanic episodes andincrease the risk for the development of rapid-cycling illness.There is evidence that lithium alone is effective in depression thathas failed to respond to tricyclic medication, and in combinationwith other antidepressants in the management of resistantdepression (see below).Affective disorders are recurrent illnesses and the discovery ofthe prophylactic effects of lithium opened a new era in theirmanagement. In a number of controlled investigations of varying