After that, Dr. Townsend recommends what he calls the "workhorse" strategy, identifying one or possibly a combination of two well-tolerated medications that are effective in controlling the patient's manic and depressive symptoms in the long-term.

What succeeds as a workhorse for one patient may fail for another. There is no formula for success other than trial and error. However, beginning with a single drug and switching until you find one that is effective, and then perhaps adding a second later if necessary, is likely to be more successful than trying out combinations of two drugs initially, Dr. Townsend said.

Non-compliance with medication is a particular problem among bipolar patients, Dr. Nard said. However, contrary to what some might assume, missing the euphoria of manic episodes is not the chief reason for non-adherence. In fact, this was the least-cited reason among non-compliant patients during a survey published in Psychopharmacology Bulletin, Dr. Nard noted.

The survey found that missing the euphoria of mania was cited by only about 2% of patients. For comparison, about 30% of those surveyed said they failed to comply with medication because of side effects, which include diabetes, sexual dysfunction, and weight gain, Dr. Nard noted.

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