Treatment Options in Bipolar Disorder: Lessons from Population-Based Registers with Focus on Lithium

Population-based register studies have the advantage of large sample sizes and low dropout rates during long-term follow-up. Recent findings from population-based register studies on the efficacy of lithium have supplemented findings from randomized trials and generalized these to all patients with bipolar disorder. Findings from population-based register studies show that (1) half of patients with bipolar disorder continue to take lithium for longer than 6 months, (2) early start of lithium maintenance treatment following the first single manic episode improves the long-term outcome, (3) maintenance treatment with lithium seems to be in general superior to treatment with valproate and lamotrigine, (4) lithium may reduce the risk of suicide and dementia, and (5) lithium-induced end-stage renal disease is rare with modern lithium treatment within recommended serum levels. Based on the accumulated evidence, lithium should be used as first-line maintenance treatment for bipolar disorder and with intensified group-based psychoeducation following onset of first manic episode/bipolar disorder to improve long-term adherence to lithium, especially among younger patients.