Remarks y This recommendation refers to people living with bipolar disorder in the maintenance phase, characterized by the absence of acute symptoms. y The use of lithium should be considered as first-line of treatment for bipolar disorder only if clinical and laboratory monitoring are available and 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, electrocardiogram (ECG) and pregnancy tests before beginning treatment where possible. y Sodium valproate should not be used in women and girls of childbearing potential because of the high risk of birth defects and neurodevelopmental disorders in children exposed to sodium valproate in utero (see recommendation PSY8.2). y Polytherapy should be avoided as a treatment option when commencing maintenance therapy.

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 or mood stabilizers should be combined with psychosocial interventions (see other recommendations in this module). y Acquisition costs can differ substantially and also throughout the world. Recent antipsychotics may have higher costs than older antipsychotics. y Discontinuities in medicine availability (common in LMICs) may interfere with the continuation of treatment. y Lithium carbonate, carbamazepine and quetiapine (therapeutic alternatives: aripiprazole, olanzapine, paliperidone) are available in the WHO EML (13).