When to stop medication

Person-centred treatment is a necessary adjunct to pharmacotherapy in terms of optimising outcomes for bipolar I patients. In this interview, Prof Young shares his experience and knowledge about incorporating other treatment modalities into the mix and why it is important to work in conjunction with the patient.

Alongside medication what techniques do you include in your treatment plans?

Medication whilst important is only ever part of a treatment plan. It should take place against the background of an accurate and comprehensive diagnosis and also an assessment of the person’s life.

In terms of other therapeutic modalities, psychotherapy plays a very important role. We are very keen on psychological approaches being used at the same time as pharmacotherapy and the notion that these are sometimes contradictory is no longer held by informed opinion.

Psychological approaches vary; there is very good evidence for psycho-educational strategies both for patients and for families and the evidence is particularly powerful for younger patients who are more embedded in the family.

There are also other more bespoke psychological treatments such as interpersonal therapy, dialectic behavioural therapy and cognitive therapy, all of which have their role. Part of psycho-education is educating people about avoiding stressors and destabilising factors and for bipolar disorder this could be summarised as leading a very healthy lifestyle with regular hours, avoiding triggers such as alcohol and jetlag; extreme time shifts can sometimes be a trigger for people with bipolar disorder.

In summary, there's a whole parcel of options that need to be personalised and tailored for the individual.

When to stop medication

Is there any evidence to show that it’s okay to discontinue mood stabilises in bipolar I disorder after five or 10 years of stability?

The issue of when to stop medication is a very difficult question to answer for all drug treatment in mood disorders including bipolar disorder. People seem to continue to benefit if they've responded to the initial treatment, for as long as the studies continue but it’s difficult to continue randomized controlled trials for more than one or two years.

We know from clinical practice where we’ve had patients who have been stable and well on mood stabilisers medicines for 5 to 10 years or even longer, that the length of time they spend well on these mood stabilisers doesn’t mean that they can stop taking them without a risk of relapse.

I think the key point here is that people have a natural tendency to think they are well in spite of the medication but they’re probably well because of the medication

This can be partly mitigated by tapering off the medication much more slowly. This is what we usually do in my clinic where we tend to gradually titrate down the medication over at least three months and possibly six. Some studies show that if you taper the medicine off faster than three months, the risk of relapse is quite high. That said, no one really knows how slowly we should do this so we do it as slowly as is practically possible and even then people can relapse despite being well.

I think the key point here is that people have a natural tendency to think they are well in spite of the medication but they’re probably well because of the medication. That’s why it’s important to share information and the uncertainty with the patient and try to work with them collaboratively.