CONTINUATION PHASE TREATMENT (see algorithm)

Acute phase treatment can last from 2-10 weeks, and the end of the acute phase is defined as a point when the patient reverts to euthymia and where the psychotic symptoms are resolved.

The acute phase of treatment presents opportunities for psychoeducation of family and friends, and building a collaborative therapeutic relationship with the patient. The patient is often only able to tolerate and digest focal bits of psychoeducational information during the acute phase.

Significant psychoeducational and psychotherapeutic interventions commonly, and appropriately, occur in the continuation phase (also called the early stable phase) which lasts for a further 6-12 weeks. Normalization of biological and social rhythms is an essential part of management too. Mood stabilizers are the mainstay of pharmacoltherapy. Neuroleptics and benzodiazepines, used for acute behavioural suppression or for rapid control of manic behavioral dyscontrol, need to be gradually discontinued over 2-3 weeks after symptom control has been achieved. Neuroleptics need to be continued well beyond the acute phase only if there is persistent or incongruent psychotic symptoms. Similarly, antidepressants can be gradually discontinued over 6-12 weeks after remission from bipolar depression provided that the patient continues to be on a mood stabilizer. However, if there is a previous history of the patient’s symptoms being exacerbated every time neuroleptics, antidepressants or other psychotropic medications are discontinued, there is justification in continuing these medications in addition to mood stabilizers during this phase and beyond. The clinician and patient should constantly weigh the benefits versus risks of continuing or discontinuing treatments. This is also the phase for active discussion with the patient and family about long term treatment and the benefits and risks of prophylactic treatment.

Serum medication levels and monitoring/investigations of bodily systems should be done as clinically indicated in the continuation phase.