Atypical antipsychotics are often used during the acute manic phase of bipolar disorder. Randomised, controlled trials have demonstrated efficacy independent of psychotic features and several are now licensed for this indication. The evidence for maintenance treatment is less clear. There is some data to suggest prevention of manic episodes and practice guidelines (APA, BAP) focus on psychotic symptoms during maintenance therapy.

Adherence with maintenance treatment in bipolar disorder is poor and yet discontinuing treatment is the most frequent cause of recurrence. Conventional depot antipsychotics have been shown to reduce the numbers of relapses in patients with frequent manic episodes, but are associated with more side effects, especially EPS.

Ten patients with bipolar disorder were treated with risperidone long-acting injection (RLAI). The average duration of illness was 10.6 years. All patients were hospitalized at the time of initiation with an average YMRS score of 25.2.

After six weeks of treatment, YMRS had decreased by 31.7% to 17.2. The average duration of treatment with RLAI was 14.6 months and by endpoint YMRS had decreased by 58.7% (from baseline) to 10.4. All ten patients have been discharged from hospital and are being maintained on RLAI with no reported side-effects.

This small study in bipolar patients suggests that treatment with RLAI is efficacious and combines the tolerability benefits of an atypical antipsychotic with the assured delivery of a long-acting injection. Randomised, controlled trials are needed to further explore the benefits of long-acting atypical antipsychotics in bipolar disorder.