A 35-Year-Old Man with a History of Bipolar Disorder Since

A 35-year-old man with a history of bipolar disorder since age 27 comes to the office for follow-up.  The patient was hospitalized 2 years ago for a manic episode and was discharged with a therapeutic dose of lithium; he continues to take the same dose and is engaged in weekly psychotherapy.  The patient says, "This is the best I've felt in years; work is going great, and I'm getting married in a few months.  I really don't want to get hospitalized again, but I also don't want to keep taking medication if I don't have to."  Prior medication trials include quetiapine and olanzapine with fluoxetine; both treatments were discontinued due to weight gain.  Medical history is noncontributory.  Vital signs and physical examination are unremarkable.  The patient appears euthymic and has a full range of affect.  Complete blood count, basic metabolic panel, and TSH are within normal limits; serum lithium level is within therapeutic range.  Which of the following is the most appropriate response to this patient?

A) "Mood episodes are often triggered by stress or change; let's continue the medication for now and begin tapering it after your wedding."
B) "Mood episodes in bipolar disorder are highly recurrent; I suggest continuing lithium at the current dose and monitoring for side effects."
C) "Since you have had no mood episodes in the past 2 years and you meet regularly for therapy, it would be reasonable to decrease your dose."
D) "We can try switching to a medication that you don't have to take daily; let's talk about the available long-acting injectable treatments."

Correct Answer:

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