Bipolar disorder (BD) is a potentially disabling illness characterized by episodes of mania, depression, hypomania or mixed states. Pharmacologic treatment of BD is based on administration of mood stabilizers and second-generation antipsychotics. Patient adherence to a treatment is very important. Many patients experience recurrence or relapse of mood episodes due to nonadherence to the treatment. Several antipsychotic trials suggested that long action injection antipsychotics (LAI) are effective in reducing relapse in BD. Paliperidone palimitate (PP) is a second-generation LAI antipsychotic agent. Because of the treatment nonadherence and the lack of treatment response, we added PP to the current medication in these two cases.

Case 1: 45 year-old female patient had 5 manic and 2 depressive episodes until the last admission to our department. One of the manic episodes were induced by leaving the medication. When she presented to our hospital, she had discontinued medications unilaterally and hospitalized with 6. manic episode. Valproic acid (VPA) treatment was started and increased to 1500 mg/day (91.25 μg/L). Because of the nonadherence to the treatments for many times and inadequate treatment response, we added PP to the treatment on the 11th day of hospitalization. Before this alteration, the Young Mania (YM) score of the patient was 22 and VPA concentration was 91.25 μg/L. After 53 days of hospitalization, her YM score was decreased from 33 to 7. During the treatment, extrapyramidal system(EPS) side effects weren’t observed and her plasma prolactin level was 97.75 μg/L at discharge. She was discharged with VPA 1000 mg/day (93.87 μg/L) and PP 100 mg monthly injection with remission.

Case 2: 53 year-old female patient who had one depressive and two manic episodes until admission to our inpatient unit and one of her manic episodes was induced with treatment discontinuation. When she presented to our clinic, she has again stopped the medication, and was hospitalized with 3. manic episode. Because of the prior benefit, VPA treatment was started and increased to 1500 mg/day. Because of the treatment nonadherence in the past and inadequate response in this follow-up PP was added to the treatment on the 28. of hospitalization. Before this alteration her YM score was 14 and VPA concentration was 64.16 μg/L. After 82 days of hospitalization, her YM score was decreased from 39 to 0. During the treatment, no EPS side effect was observed and her plasma prolactin level was 46.34 μg/L at discharge. She was discharged with VPA 2000 mg/day (76.09 μg/L) and PP 100 mg monthly injection with remission and full insight. Until now data about the use of LAI atypical antipsychotic are very limited. Combinations of mood stabilizers with atypical antipsychotics can be taken into consideration in case of psychotic or severe forms of BD. However, combined treatments may be a problem in the case of poor-adherent patients, and LAI formulations of atypical antipsychotics can be a therapeutic option in these situations. PP therefore may be a therapeutic option in BD which has severe symptoms, psychotic features, and poor adherence to pharmacological treatment. 

Keywords: bipolar disorder, long action injection antipsychotic, paliperidone palmitate