Remarks y Remission is considered when there is absence of or minimal symptoms for several weeks. Remission, defined as the absence of or minimal symptoms for several weeks, was not necessarily an inclusion criteria in the trials included in the reviews. y Maintenance therapy was used in the recommendation to define continuation of treatment with a lack of acute symptoms. y Maintenance treatment should only be offered in primary health care settings where clinical supervision is able to be provided by a mental health specialist. y In situations where one of the listed secondgeneration antipsychotics are not a feasible option for treatment, first-generation antipsychotics, namely chlorpromazine or haloperidol, may be considered for maintenance treatment for adults living with bipolar disorder. y The use of lithium should be considered as first-line of treatment for bipolar disorder only if clinical and laboratory monitoring are available. Lithium should only be prescribed under mental health specialist supervision. If laboratory examinations are not available or feasible, lithium should be avoided and other mood stabilizers or antipsychotics should be considered. Do not prescribe lithium where the lithium supply may be frequently interrupted due to increased risk of relapse. Clinicians should conduct kidney and thyroid function, complete blood count, ECG and pregnancy tests before beginning treatment where possible.

Implementation considerations y People living with bipolar disorder should be involved in medicine choice in a supported decision-making process. y Treatment with antipsychotic medicines/mood stabilizers should be combined with psychosocial interventions (see other PICO questions in this module). y Acquisition costs can differ substantially and also throughout the world. Recent antipsychotics may have higher costs than older antipsychotics. y Lithium, sodium valproate and carbamazepine require regular blood monitoring, which also adds costs. y Lithium carbonate, sodium valproate (valproic acid), carbamazepine and quetiapine (therapeutic alternatives: aripiprazole, olanzapine, paliperidone) are available in the WHO EML (13).