Sir,
Bipolar disorder (BD) is a chronic illness characterized by recurrent mood episodes, necessitating long-term pharmacological stabilization. Medication non-adherence is a leading cause of relapse, resulting in frequent hospitalizations, functional decline, and high healthcare costs. Although conventional mood stabilizers such as lithium and valproate remain first-line agents, their effectiveness is often undermined by poor adherence.
Long-acting injectable (LAI) antipsychotics, widely employed in schizophrenia, provide steady drug exposure and improve adherence. Their role in the management of BD is less explored, especially with first-generation agents which are not recommended as maintenance treatment in the current guidelines.[1] Evidence suggests haloperidol, fluphenazine, and zuclopenthixol depots may be effective for preventing manic relapses, though data remain limited compared to schizophrenia.[2] Haloperidol has also shown efficacy in acute mania compared to lithium.[3] Recent real-world analyses confirm LAIs’ capacity to reduce hospitalizations and relapse risk in BD.[4] This case highlights haloperidol decanoate as a cost-effective option to prevent manic relapses in a patient with poor adherence to oral medication.
A 50-year- old woman, with an ICD-10 diagnosis of bipolar disorder, had experienced approximately 30 manic episodes over the course of 25 years, nearly all requiring hospitalization and adjunctive electroconvulsive therapy (ECT). Symptoms included overtalkativeness, reduced need for sleep, grandiose and bizarre delusions, increased psychomotor activity, and euphoria. She had no depressive or mixed episodes, no rapid cycling, and no substance misuse; there was no family history of any psychiatric illness.
She underwent adequate trials of lithium, valproate, clozapine, risperidone, olanzapine, and oral haloperidol, alone and in various combinations. Adherence to oral medications was consistently poor, possibly due to perceived side effects of weight gain and limited insight, leading to frequent relapses.
Haloperidol decanoate (100 mg intramuscularly every 4 weeks) was initiated in 2019 to address non-adherence. This produced two prolonged remission periods lasting 2.5 years and 2 years, respectively, the longest in her illness course. She remained euthymic, functional, and experienced no extrapyramidal, or other side effects. She was on monthly follow-ups and received oral trihexyphenidyl throughout this period.
At the patient’s request, the depot was replaced with oral haloperidol (10 mg/day) as she found the injections inconvenient. However, adherence to oral medication was mostly poor due to impaired insight. Within six months, she relapsed into mania, requiring hospitalization and ECT. Reintroduction of haloperidol decanoate restored stability.
This case underscores haloperidol decanoate’s role in maintaining remission in a patient with chronic non-adherence and mania-predominant BD. Depot formulations may be particularly effective in preventing manic relapses, consistent with reviews highlighting their utility in BD.[2] Haloperidol’s robust antimanic effect associated with significant D2 receptor blockade is well-established.[5]
Real-world evidence further supports LAIs: mirror-image studies show significant reductions in rehospitalizations and relapses following their initiation.[4] Haloperidol depot offers additional advantages in resource-limited contexts, being inexpensive, widely available, and effective in patients where adherence is the key barrier.
Haloperidol decanoate was associated with the longest periods of remission in this patient with chronic, BD with poor adherence to oral treatment. Its affordability and accessibility highlight its potential as a pragmatic maintenance strategy in resource-limited settings, especially for mania prevention. However, monitoring of possible side effects such as EPS (extrapyramidal symptoms) and tardive dyskinesia is required. The choice of depot should be made after a careful risk-benefit analysis and psychoeducation. Larger trials are needed to establish its efficacy across mood phases and to compare it with atypical LAIs.
Declaration of patient consent
The authors certify that they have obtained the appropriate patient consent form. In the form, the patient has given her consent for her clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.
Conflicts of interest
There are no conflicts of interest.
Funding Statement
Nil.
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