Defining and improving response to treatment in patients with bipolar disorder.

Functional outcomes are more meaningful measures of response to treatment for bipolar disorder than are scores on various psychiatric rating scales (all of which have limitations) used to gauge improvement in symptoms. With the former approach, patients are considered to be in remission if they achieve normal or near-normal levels of functioning in occupational, family, and social settings. Sleep patterns are reliable indicators of whether a patient with bipolar disorder is likely to relapse or sustain remission in the near term. Regularly scheduled nightly sleep periods may help prevent rapid cycling in patients with mania, while perturbations in circadian rhythms may be early markers of impending relapse. Medications used to attain response and/or remission in maintenance therapy include lithium and valproate. The choice of mood stabilizer depends on the patient's symptoms, prior response to a mood stabilizer, and tolerance of the drug. For patients requiring additional therapy, combination regimens with mood stabilizers and atypical antipsychotics appear effective. Psychoeducation for patients and families and interpersonal psychotherapy also can help prolong remission.