Acute treatment for mania and depression should be continued for four weeks after symptoms resolve (usually between three and six months) at which point long-term drug treatment options should be considered. 

Discontinuation of long-term treatment for bipolar disorder must be done carefully, as relapses can occur even after many years of sustained remission. Abrupt discontinuation of treatment is associated with an increased risk of early relapse of mania so doses should be gradually tapered over at least four weeks, preferably longer. For lithium discontinuation over three months is preferable.

Patients should be monitored for signs of relapse, emerging symptoms, mood and mental state while discontinuing treatment, and for up to two years after treatment has stopped. 

Key facts

• Haloperidol, olanzapine, quetiapine and risperidone are the antipsychotics of choice for the treatment of mania
• Antidepressants should only be used for treating bipolar depression or long-term treatment if they are prescribed in combination with an antipsychotic 
• Lithium is the most effective long-term treatment for bipolar disorder
• Sodium valproate should be avoided in women of child-bearing age
• If lithium is used, plasma levels, thyroid function and electrolyte levels should be checked regularly 
• Adherence to medication is crucial in the long term as the risk of relapse remains high even after many years of sustained remission.