Psychotropic drug prescription patterns among patients with bipolar I disorder

International Trends in Lithium Use for Pharmacotherapy and Clinical Correlates in Bipolar Disorder: A Scoping Review

Lithium remains an effective option in the treatment of bipolar disorder (BD). Thus, we aim to characterize the pharmaco-epidemiological patterns of lithium use internationally over time and elucidate clinical correlates associated with BD using a scoping review, which was conducted using the methodological framework by Arksey and O'Malley (2005). We searched several databases for studies that examined the prescriptions for lithium and clinical associations in BD from inception until December 2023. This review included 55 articles from 1967 to 2023, which collected data from North America (n = 24, 43.6%), Europe (n = 20, 36.4%), and Asia (n = 11, 20.0%). The overall prescription rates ranged from 3.3% to 84% (33.4% before and 30.6% after the median year cutoffs). Over time, there was a decline in lithium use in North America (27.7% before 2010 to 17.1% after 2010) and Europe (36.7% before 2003 to 35.7% after 2003), and a mild increase in Asia (25.0% before 2003 to 26.2% after 2003). Lithium use was associated with specific demographic (e.g., age, male gender) and clinical factors (e.g., lower suicide risk). Overall, we found a trend of declining lithium use internationally, particularly in the West. Specific clinical correlates can support clinical decision-making for continued lithium use.

Preventive Medication Patterns in Bipolar Disorder and Their Relationship With Comorbid Substance Use Disorders in a Cross-National Observational Study

OBJECTIVE

The potential role of sub-optimal pharmacological treatment in the poorer outcomes observed in bipolar disorder (BD) with vs. without comorbid substance use disorders (SUDs) is not known. Thus, we investigated whether patients with BD and comorbid SUD had different medication regimens than those with BD alone, in samples from France and Norway, focusing on compliance to international guidelines.

METHODS

Seven hundred and seventy patients from France and Norway with reliably ascertained BD I or II (68% BD-I) were included. Medication information was obtained from patients and hospital records, and preventive treatment was categorized according to compliance to guidelines. We used Bayesian and regression analyses to investigate associations between SUD comorbidity and medication. In the Norwegian subsample, we also investigated association with lack of medication.

RESULTS

Comorbid SUDs were as follows: current tobacco smoking, 26%, alcohol use disorder (AUD), 16%; cannabis use disorder (CUD), 10%; other SUDs, 5%. Compliance to guidelines for preventive medication was lacking in 8%, partial in 44%, and complete in 48% of the sample. Compliance to guidelines was not different in BD with and without SUD comorbidity, as was supported by Bayesian analyses (highest Bayes Factor = 0.16). Cross national differences in treatment regimens led us to conduct country-specific adjusted regression analyses, showing that (1) CUD was associated with increased antipsychotics use in France (OR = 2.4, 95% CI = 1.4-3.9, p = 0.001), (2) current tobacco smoking was associated with increased anti-epileptics use in Norway (OR = 4.4, 95% CI = 1.9-11, p < 0.001), and (3) AUD was associated with decreased likelihood of being medicated in Norway (OR = 1.2, 95% CI = 1.04-1.3, p = 0.038).

CONCLUSION

SUD comorbidity in BD was overall not associated with different pharmacological treatment in our sample, and not related to the level of compliance to guidelines. We found country-specific associations between comorbid SUDs and specific medications that warrant further studies.

Patient educational level and management of bipolar disorder

BACKGROUND

Socioeconomic factors can affect healthcare management.

AIMS

The aim was to investigate if patient educational attainment is associated with management of bipolar disorder.

METHOD

We included patients with bipolar disorder type 1 (n = 4289), type 2 (n = 4020) and not otherwise specified (n = 1756), from the Swedish National Quality Register for Bipolar Disorder (BipoläR). The association between patients' educational level and pharmacological and psychological interventions was analysed by binary logistic regression. We calculated odds ratios after adjusting for demographic and clinical variables.

RESULTS

Higher education was associated with increased likelihood of receiving psychotherapy (adjusted odds ratio 1.34, 95% CI 91.22-1.46) and psychoeducation (adjusted odds ratio 1.18, 95% CI 1.07-1.46), but with lower likelihood of receiving first-generation antipsychotics (adjusted odds ratio 0.76, 95% CI 0.62-0.94) and tricyclic antidepressants (adjusted odds ratio 0.76, 95% CI 0.59-0.97). Higher education was also associated with lower risk for compulsory in-patient care (adjusted odds ratio 0.79, 95% CI 0.67-0.93).

CONCLUSIONS

Pharmacological and psychological treatment of bipolar disorder differ depending on patients' educational attainment. The reasons for these disparities remain to be explained.

A taxonomy of clinical response to mood stabilizers

INTRODUCTION

Although clinical practice guidelines (CPG) identify first, second- and third-line mood stabilizer (MS) treatments, they rarely define clinical response to prophylaxis or the core issues to be considered. This project aimed to develop a template for describing how clinical response may be classified and a framework to assist decision-making and monitoring of response in day-to-day practice.

METHOD

A scoping exercise was undertaken followed by narrative synthesis of (a) qualitative and quantitative definitions of MS response applied in clinical and research practice and (b) potential confounders (eg, non-adherence; tolerability issues) of relevance to routine practice, for example, the concepts are applicable to individuals with bipolar disorder for whom sustained remission is a less realistic goal. Expert consensus was employed to develop a taxonomy of response and key concepts that inform clinical judgements about MS response.

RESULTS

Five core constructs can be used to systematize clinical judgements regarding MS response and its monitoring: (a) quantitative, qualitative and/or patient-reported outcome measures (PROMS), (b) personalized assessment of the acceptable benefit-to-harm ratio of a proposed treatment, (c) adequacy of treatment exposure (dose, duration, therapeutic monitoring and adherence), (d) illness activity pre- and post-MS initiation, and (e) other potential confounders (co-prescription of MS; polypharmacy) or protective factors (eg, psychosocial factors).

CONCLUSIONS

This heuristic framework might be used as a teaching aid or by clinicians who wish to take a more systematic approach to developing shared criteria for judging MS response that better match patient expectations and preferences. Heuristic approaches also allow seamless introduction of new evidence.

Mental health dished up-the use of iPSC models in neuropsychiatric research

Genetic and molecular mechanisms that play a causal role in mental illnesses are challenging to elucidate, particularly as there is a lack of relevant in vitro and in vivo models. However, the advent of induced pluripotent stem cell (iPSC) technology has provided researchers with a novel toolbox. We conducted a systematic review using the PRISMA statement. A PubMed and Web of Science online search was performed (studies published between 2006–2020) using the following search strategy: hiPSC OR iPSC OR iPS OR stem cells AND schizophrenia disorder OR personality disorder OR antisocial personality disorder OR psychopathy OR bipolar disorder OR major depressive disorder OR obsessive compulsive disorder OR anxiety disorder OR substance use disorder OR alcohol use disorder OR nicotine use disorder OR opioid use disorder OR eating disorder OR anorexia nervosa OR attention-deficit/hyperactivity disorder OR gaming disorder. Using the above search criteria, a total of 3515 studies were found. After screening, a final total of 56 studies were deemed eligible for inclusion in our study. Using iPSC technology, psychiatric disease can be studied in the context of a patient’s own unique genetic background. This has allowed great strides to be made into uncovering the etiology of psychiatric disease, as well as providing a unique paradigm for drug testing. However, there is a lack of data for certain psychiatric disorders and several limitations to present iPSC-based studies, leading us to discuss how this field may progress in the next years to increase its utility in the battle to understand psychiatric disease.

Attitude and perceptions of patients towards long acting depot injections (LAIs)

BACKGROUND

Despite the well-established efficacy of the long acting depot injectable (LAIs) antipsychotics, these are significantly underused and underutilized by the mental health professionals, with a belief that patients will not accept the same.

AIMS & OBJECTIVES

To explore the acceptability and perception of patients towards various psychiatric treatments, with specific focus on LAIs. Additionally the study aimed to compare the acceptability of various types of treatments including LAIs between patients with severe mental disorders (Psychotic disorders and Bipolar disorder) and those with Common mental disorders (Anxiety, neurotic and depressive disorders).

METHODOLOGY

A self-designed semi-structured questionnaire was used to evaluate the preferred treatment options of all the new patients attending the psychiatry outpatient clinic of a tertiary care hospital. Depending on the response, they were further probed for the reasons for accepting or rejecting the LAIs.

RESULTS

2659 patients were interviewed who were divided into two groups (Group I - 321 subjects with psychotic disorders and 120 subjects with bipolar affective disorder (BPAD) and Group II - 2218 subjects with neurotic, stress-related and unipolar depressive disorders). More than three-fourth (78.8%) of the participants in the whole study sample opted for tablets only as their first preferred choice and injectables were opted by about 5% of the participants only, with no significant difference between the 2 groups. After being explained about LAIs, one fourth of the participants (24.9%) reported that they may consider LAIs, without any significant difference between the 2 groups. Among those who refused to take LAIs even after explanation, the commonly reported reasons were difficulty in visiting hospital frequently for the injectables (41.69%), injectables being painful (19.41%), fear of injections (13.96%), no need to take LAIs (12.45%) and preference to take some other types of medicines (8.52%).

CONCLUSIONS

Considering the fact that LAIs are highly underused in patients with severe mental disorders and there is lack of awareness about LAIs among patients with severe mental disorders, the present study findings suggest that there is reasonable level of acceptance of LAIs among patients with severe mental disorders when explained about the same.

Complex psychotropic polypharmacy in bipolar disorder across varying mood polarities: A prospective cohort study of 2712 inpatients

BACKGROUND

It is common for patients with bipolar disorder (BP) to receive multiple psychotropics, but few studies have assessed demographic and clinical features associated with risk for receiving complex psychotropic polypharmacy.

METHODS

This longitudinal cohort study examined 2712 inpatients with a DSM-IV clinical diagnosis of BP to assess associations between complex polypharmacy (defined as ≥4 psychotropics) and demographic and clinical features; associations with risk of rehospitalization were also examined. Logistic regressions were performed with the sample as a whole and with each of four DSM-IV BP subtypes individually.

RESULTS

Complex polypharmacy was present in 21.0%. BP-I depressed patients were more likely to receive complex regimens than BP-I manic, BP-I mixed or BP-II patients. In the sample as a whole, variables significantly associated with complex polypharmacy included female, white, psychotic features and a co-diagnosis of borderline personality, post-traumatic stress or another anxiety disorder. The only examined medication not significantly associated with complex polypharmacy was lithium, although only in BP-I depressed and BP-I mixed. Complex polypharmacy was associated with rehospitalization in BP-I mania within 15 and 30days post index hospitalization.

LIMITATIONS

All data were from one clinical facility; results may not generalize to other settings and patient populations.

CONCLUSIONS

BP-I depression may pose a greater treatment challenge than the other BP subtypes. Lithium may confer an overall advantage compared to other medications in BP-I depressed and BP-I mixed. Further research is needed to guide pharmacotherapy decisions in BP patients.

Lithium: A classic drug-Frequently discussed, but, sadly, seldom prescribed!

OBJECTIVE

Distinguished authors in the field have repeatedly alerted psychiatrists of the alarming trends in the treatment of bipolar disorders: decline of lithium use, paralleled by the increase of prescribing anticonvulsants and second-generation antipsychotic drugs. Research has been conducted in order to explore the factors that led to this development and to provide arguments for the need to reverse this trend.

METHOD

This paper represents a narrative review of the literature containing retrieved research articles focusing on the efficacy of lithium. The papers included in this overview were published prior to June 2016; additional papers were identified by searching the reference lists of reviewed articles. Taking into account the amount of literature available, no search can be exhaustive; on the other hand, the studies consulted, all of which explore the effectiveness of various compounds, may have their own limitations as well.

RESULTS

The evidence of the effectiveness of lithium in the treatment of acute mania, acute bipolar depression and the prevention of manic and depressive episodes is compelling. Lithium is the most effective augmentation agent in treatment-resistant depression. Its anti-suicidal effects are well established. The neuroprotective effects of lithium have been demonstrated in case-control studies and in population-based research. It has been established that starting lithium early in the course of the disorder reduces the rates of treatment non-response.

CONCLUSIONS

Despite abundant evidence regarding the efficacy of lithium and its effectiveness in the treatment of bipolar disorders, its use is declining at the beginning of the 21st century. It is of paramount importance to keep reminding psychiatrists and educating physicians about the unique properties of lithium and about monitoring patients treated with lithium, since it has been suggested that lithium should once again become the first-line treatment for bipolar disorders.

Weight gain with add-on second-generation antipsychotics in bipolar disorder: a naturalistic study

OBJECTIVE

Our aim was to investigate the prevalence and magnitude of weight gain in-patients with bipolar disorder when treated with a second-generation antipsychotic as an add-on treatment to a mood stabilizer in routine clinical practice.

METHODS

Data were derived from the quality register for bipolar disorder in Sweden (BipoläR). Patients with bipolar disorder who started add-on treatment with a SGA (n = 575) were compared at next yearly follow-up with age and sex matched patients who were only treated with a mood stabilizer (n = 566). The primary outcome measure was change in body weight and body mass index (BMI). We also assessed the prevalence of clinically significant weight gain defined as ≥7% gain in body weight.

RESULTS

The group that received add-on treatment with antipsychotics neither gained more weight nor were at higher risk for a clinically significant weight gain than the reference group. Instead, factors associated with clinically significant weight gain were female sex, young age, low-baseline BMI, and occurrence of manic/hypomanic episodes.

CONCLUSION

We found no evidence of an overall increased risk of weight gain for patients with bipolar disorder after receiving add-on SGA to a mood stabilizer in a routine clinical setting.

Utilization of Psychopharmacological Treatment Among Patients With Newly Diagnosed Bipolar Disorder From 2001 to 2010

OBJECTIVE

The aim of the study was to examine utilization and patterns of psychopharmacological treatment during a 1-year follow-up period among patients with newly diagnosed bipolar disorder from 2001 to 2010.

METHODS

Patients with newly diagnosed bipolar disorder from 2001 to 2010 were identified from the National Health Insurance Research Database in Taiwan. We assessed prescription records related to 4 kinds of psychopharmacological medication, including antipsychotics (APs), antidepressants, mood stabilizers, and benzodiazepines, as well as health care utilization in a 1-year follow-up period among the study subjects. In addition, logistic regressions were applied to test the trends for utilization of psychopharmacological treatment during the 10-year study period.

RESULTS

A total of 2703 patients newly diagnosed with bipolar disorder were enrolled. The ratio of good adherence, defined as medications possession ratio greater than 0.8, for use of the examined psychopharmacological medication was relatively low during the study period. The use of first-generation APs, selective serotonin reuptake inhibitors, tricyclic antidepressants, lithium, carbamazepine, and benzodiazepines has declined; however, the use of second-generation APs, serotonin and norepinephrine reuptake inhibitors, lamotrigine, and valproate has risen markedly during the 10-year period.

CONCLUSIONS

This study presents patterns of pharmacological treatment in patients with newly diagnosed bipolar disorder in Taiwan for a 10-year study period. It would be of importance to further investigate causes and outcomes for polytherapy and nonadherence to psychotropic medications among patients with bipolar disorder.

Prevalence and clinical features associated with bipolar disorder polypharmacy: a systematic review

BACKGROUND

Uncertainty exists regarding the prevalence and clinical features associated with the practice of polypharmacy in bipolar disorder (BD), warranting a systematic review on the matter.

METHODS

Three authors independently searched major electronic databases from inception till September 2015. Articles were included that reported either qualitative or quantitative data about the prevalence and clinical features associated with polypharmacy in adult cases of BD.

RESULTS

The operative definitions of polypharmacy adopted across varying studies varied, with concomitant use of two or more psychotropic medications or use of four or more psychotropic medications at once being the most common and the most reliable, respectively. Regardless of type or current mood episode polarity of BD, prevalence rates up to 85% and 36% were found using the most permissive (two or more medications at once) and the most conservative (four or more) operative definitions for polypharmacy, respectively. Point prevalence prescription rates of one or more antidepressant or antipsychotic as part of a polypharmacy regimen occurred in up to 45% or 80% of the cases, respectively, according to the most permissive definition of polypharmacy. In contrast, lithium prescription rates ranged from 13% to 33% in BD patients receiving polypharmacy according to conservative and permissive definitions, possibly suggesting a reduced need for augmentation of combination strategies for those cases of BD with a favorable lifetime lithium response and/or long-lasting treatment as well as less likelihood of lithium response over the time most severe cases possibly exposed to a more complex polypharmacy overall.

LIMITATIONS

"Apples and oranges" bias; publication bias for most recently introduced compounds.

CONCLUSION

Polypharmacy is common among people with BD across varying type and mood episode phases of illness. Special population, including BD patients at high risk of familial load for suicidal behavior, solicit further research as well as the plausible "protective" role of lithium toward polypharmacy in BD. The PROSPERO registration number is CRD42014015084.

Unmet needs of bipolar disorder patients

BACKGROUND

Bipolar disorder (BD) is a serious mental illness with adverse impact on the lives of the patients and their caregivers. BD is associated with many limitations in personal and interpersonal functioning and restricts the patients' ability to use their potential capabilities fully. Bipolar patients long to live meaningful lives, but this goal is hard to achieve for those with poor insight. With progress and humanization of society, the issue of patients' needs became an important topic. The objective of the paper is to provide the up-to-date data on the unmet needs of BD patients and their caregivers.

METHODS

A systematic computerized examination of MEDLINE publications from 1970 to 2015, via the keywords "bipolar disorder", "mania", "bipolar depression", and "unmet needs", was performed.

RESULTS

Patients' needs may differ in various stages of the disorder and may have different origin and goals. Thus, we divided them into five groups relating to their nature: those connected with symptoms, treatment, quality of life, family, and pharmacotherapy. We suggested several implications of these needs for pharmacotherapy and psychotherapy.

CONCLUSION

Trying to follow patients' needs may be a crucial point in the treatment of BD patients. However, many needs remain unmet due to both medical and social factors.

Assessing cognitive function in bipolar disorder: challenges and recommendations for clinical trial design

OBJECTIVE

Neurocognitive impairment in schizophrenia has been recognized for more than a century. In contrast, only recently have significant neurocognitive deficits been recognized in bipolar disorder. Converging data suggest the importance of cognitive problems in relation to quality of life in bipolar disorder, highlighting the need for treatment and prevention efforts targeting cognition in bipolar patients. Future treatment trials targeting cognitive deficits will be met with methodological challenges due to the inherent complexity and heterogeneity of the disorder, including significant diagnostic comorbidities, the episodic nature of the illness, frequent use of polypharmacy, cognitive heterogeneity, and a lack of consensus regarding measurement of cognition and outcome in bipolar patients. Guidelines for use in designing future trials are needed.

PARTICIPANTS

The members of the consensus panel (each of the bylined authors) were selected based upon their expertise in bipolar disorder. Dr Burdick is a neuropsychologist who has studied cognition in this illness for 15 years; Drs Ketter, Calabrese, and Goldberg each bring considerable expertise in the treatment of bipolar disorder, both within and outside of controlled clinical trials. This consensus statement was derived from work together at scientific meetings (eg, symposium presentation at the 2014 Annual Meeting of the American Society of Clinical Psychopharmacology, among others) and ongoing discussions by conference call. With the exception of the public presentations on this topic, these meetings were closed to outside participants.

EVIDENCE

A literature review was undertaken by the authors to identify illness-specific challenges relevant to the design and conduct of treatment trials targeting neurocognition in bipolar disorder. Expert opinion from each of the authors guided the consensus recommendations.

CONSENSUS PROCESS

Consensus recommendations, reached by unanimous opinion of the authors, are provided here as a preliminary guide for future trial design. Recommendations comprise exclusion of certain syndromal-level comorbid diagnoses and current affective instability, restrictions on numbers and types of medications, and use of prescreening assessment to ensure enrollment of subjects with adequate objective evidence of baseline cognitive impairment.

CONCLUSIONS

Clinical trials to address cognitive deficits in bipolar disorder face distinctive design challenges. As such trials move from proof-of-concept to confirmation of clinical efficacy, it will be important to incorporate distinctive design modifications to adequately address these challenges and increase the likelihood of demonstrating cognitive remediation effects. The field is now primed to address these challenges, and a comprehensive effort to formalize best practice guidelines will be a critically important next step.

Complexity of illness and adjunctive benzodiazepine use in outpatients with bipolar I or II disorder: results from the Bipolar CHOICE study

Benzodiazepines are widely prescribed for patients with bipolar disorders in clinical practice, but very little is known about the subtypes of patients with bipolar disorder or aspects of bipolar illness that contribute most to benzodiazepine use. We examined the prevalence of and factors associated with benzodiazepine use among 482 patients with bipolar I or II disorder enrolled in the Bipolar CHOICE study. Eighty-one subjects were prescribed benzodiazepines at study entry and were considered benzodiazepine users. Stepwise logistic regression was used to model baseline benzodiazepine use versus nonuse, using entry and exit criteria of P < 0.1. In bivariate analyses, benzodiazepine users were prescribed a significantly higher number of other psychotropic medications and were more likely to be prescribed lamotrigine or antidepressants as compared with benzodiazepine nonusers. Benzodiazepine users were more likely to have a diagnosis of bipolar I disorder and comorbid anxiety disorder, but not comorbid alcohol or substance use disorders. Benzodiazepine users also had experienced more anxiety and depressive symptoms and suicidality, but not irritability or manic symptoms, than did benzodiazepine nonusers. In the multivariate model, anxiety symptom level (regardless of diagnosis), lamotrigine use, number of concomitant psychotropic medications, college education, and high household income predicted benzodiazepine use. Benzodiazepine use in patients with bipolar disorders is associated with greater illness complexity as indicated by a higher number of concomitant psychotropic medications and higher anxiety symptom burden, regardless of a comorbid anxiety disorder diagnosis. Demographic factors were also important determinants of benzodiazepine use, which may be related to access to care and insurance coverage for benzodiazepines.

Results from an online survey of patient and caregiver perspectives on unmet needs in the treatment of bipolar disorder

OBJECTIVE

To look at the manner in which patients and caregivers perceive the treatment of bipolar disorder compared with the evidence base for bipolar treatment.

METHOD

Between April 2013 and March 2014, 469 respondents took a 14-question online survey on demographics, medications taken, and perspectives on bipolar treatment and medications. Participants were recruited through social media outlets (Facebook and Twitter accounts) of Global Medical Education (New York, New York) and the blog Bipolar Burble, which has a primary audience of people with bipolar disorder. There were no exclusion criteria to participation, and both patients and health care professionals were encouraged to participate.

RESULTS

Most respondents were taking ≥ 3 medications, and the greatest unmet need in treatment was for bipolar depression. In general, respondent perspectives on the effectiveness of individual medication treatments did not align with the available literature. Weight gain was the greatest side effect concern for both antipsychotics and mood stabilizers.

CONCLUSIONS

Our survey demonstrates that there are still many unmet needs in the treatment of bipolar disorder. There is also a mismatch between the evidence base for treatments in bipolar disorder and patient perception of the relative efficacy of different medications. In order to achieve better outcomes, there is a need to provide patients and clinicians greater quality education with regard to the best evidence-based treatments for bipolar disorder.

Indian Psychiatric Society multicentric study: Prescription patterns of psychotropics in India

BACKGROUND

There is a lack of national level data from India on prescription of psychotropics by psychiatrists.

AIM AND OBJECTIVE

This study aimed to assess the first prescription handed over to the psychiatrically ill patients whenever they contact a psychiatrist.

MATERIALS AND METHODS

Data were collected across 11 centers. Psychiatric diagnosis was made as per the International Classification of Diseases Classification of Mental and Behavioural Disorders 10(th) edition criteria based on Mini International Neuropsychiatric Interview, and the data of psychotropic prescriptions was collected.

RESULTS

Study included 4480 patients, slightly more than half of the subjects were of male (54.8%) and most of the participants were married (71.8%). Half of the participants were from the urban background, and about half (46.9%) were educated up to or beyond high school. The most common diagnostic category was that of affective disorders (54.3%), followed by Neurotic, stress-related and somatoform disorders (22.2%) and psychotic disorders (19.1%). Other diagnostic categories formed a very small proportion of the study participants. Among the antidepressants, most commonly prescribed antidepressant included escitalopram followed by sertraline. Escitalopram was the most common antidepressant across 7 out of 11 centers and second most common in three centers. Among the antipsychotics, the most commonly prescribed antipsychotic was olanzapine followed by risperidone. Olanzapine was the most commonly prescribed antipsychotic across 6 out of 11 centers and second most common antipsychotic across rest of the centers. Among the mood stabilizers valproate was prescribed more often, and it was the most commonly prescribed mood stabilizer in 8 out of 11 centers. Clonazepam was prescribed as anxiolytic about 5 times more commonly than lorazepam. Clonazepam was the most common benzodiazepine prescribed in 6 out of the 11 centers. Rate of polypharmacy was low.

CONCLUSION

Escitalopram is the most commonly prescribed antidepressant, olanzapine is the most commonly prescribed antipsychotic and clonazepam is most commonly prescribed benzodiazepine. There are very few variations in prescription patterns across various centers.

Medication burden in bipolar disorder: a chart review of patients at psychiatric hospital admission

Individuals with bipolar disorder (BD) often receive complex polypharmacy regimens as part of treatment, yet few studies have sought to evaluate patient characteristics associated with this high medication burden. This retrospective chart review study examined rates of complex polypharmacy (i.e., ≥4 psychotropic medications), patterns of psychotropic medication use, and their demographic and clinical correlates in a naturalistic sample of adults with bipolar I disorder (BDI; N=230) presenting for psychiatric hospital admission. Using a computer algorithm, a hospital administrator extracted relevant demographic, clinical, and community treatment information for analysis. Patients reported taking an average of 3.31 (S.D.=1.46) psychotropic medications, and 5.94 (S.D.=3.78) total medications at intake. Overall, 82 (36%) met criteria for complex polypharmacy. Those receiving complex polypharmacy were significantly more likely to be female, to be depressed, to have a comorbid anxiety disorder, and to have a history of suicide attempt. Women were significantly more likely than men to be prescribed antidepressants, benzodiazepines, and stimulants, even after controlling for mood episode polarity. Study data highlight the high medication burden experienced by patients with BD, especially those who are acutely symptomatic. Data also highlight the particularly high medication burden experienced by women with BD; a burden not fully accounted for by depression.

Carbamazepine extended-release capsules: a new treatment option for bipolar I disorder

Carbamazepine has a long history in psychiatry and neurology. More recently, carbamazepine extended-release capsules have been approved by the US Food and Drug Administration for the treatment of manic and mixed episodes associated with bipolar I disorder. This decision represents a significant step forward for the agent, which was first described to have efficacy in the disorder in the early 1970s. Approval of carbamazepine extended-release capsules was aided by two large placebo-controlled, 3-week trials. Using nearly identical protocols, these trials demonstrated that monotherapy with carbamazepine extended-release capsules was effective for the treatment of acute mania in patients with bipolar I disorder. Recent data collected based on this new formulation of carbamazepine illustrate the need for education about the utility of this compound in bipolar disorder.

Using comparative effectiveness design to improve the generalizability of bipolar treatment trials data: contrasting LiTMUS baseline data with pre-existing placebo controlled trials

BACKGROUND

Efficacy-based double-blind placebo controlled trials were conducted to establish efficacy and safety for FDA approval. Such designs allowed and encouraged the use of exclusion criteria to improve assay sensitivity and internal validity. The LiTMUS trial increased the representation of real-world individuals with bipolar disorder despite the acknowledgment that this compromises assay sensitivity.

METHOD

To maximize generalizability, LiTMUS used broad inclusion and narrow exclusion criteria: participants experiencing mood symptoms of sufficient intensity (at least with a CGI-BP ≥ 3) that would warrant a change in treatment, and that lithium treatment would be a reasonable therapeutic option if they were randomized to it. At baseline demographic, illness, clinical, and treatment characteristics were collected. The LiTMUS study design and baseline sociodemographic data were compared to previous efficacy studies.

RESULTS

As compared to the previous bipolar disorder efficacy studies, LiTMUS participants were of similar age, gender, weight and illness severity; however LiTMUS participants were more racially and ethnically representative of the general population, had a greater number of mood episodes in the past 12 months, more Axis I/II comorbidity, a greater number of prior suicide attempts, and higher functional capacity.

CONCLUSIONS

LiTMUS was a comparative effectiveness trial that had broad inclusion and minimal exclusion criteria that produced a more representative sample comprised of real-world participants. This design enables the results of the LiTMUS study to be a more representative of real world pharmacotherapuetic outcomes.

LIMITATIONS

Limitations include possible selection bias, paucity of sociodemographic data in efficacy trials, and lack of a placebo.

Pharmacotherapy for bipolar disorder and concordance with treatment guidelines: survey of a general population sample referred to a tertiary care service

BACKGROUND

Many new approaches have been adopted for the treatment of bipolar disorder (BD) in the past few years, which strived to produce more positive outcomes. To enhance the quality of care, several guideline recommendations have been developed. For study purposes, we monitored the prescription of psychotropic drugs administered to bipolar patients who had been referred to tertiary care services, and assessed the degree to which treatment met specific guidelines.

METHODS

Between December 2006 and February 2009, we assessed 113 individuals suffering from BD who had been referred to the Royal Ottawa Mental Health Centre (ROMHC) Mood Disorders Program by physicians within the community, mostly general practitioners. The Structured Clinical Interview for DSM-IV-TR was used to assess diagnosis. The prescribed treatment was compared with specific Canadian guidelines (CANMAT, 2009). Univariate analyses and logistic regression were used to assess the contribution of demographic and clinical factors for concordance of treatment with guidelines.

RESULTS

Thirty-two subjects had BD type I (BD-I), and 81 subjects had BD type II (BD-II). All subjects with BD-I, and 90% of the BD-II group were given at least one psychotropic treatment. Lithium was more often prescribed for subjects with BD-I (62%) than those with BD-II (19%). Antidepressants were the most frequently prescribed class of psychotropics. Sixty-eight percent of subjects received treatment concordant with guidelines by medication and dose. The presence of a current hypomanic episode was independently associated with poorer concordance to guidelines. In more than half the cases, the inappropriate use of antidepressants was at the origin of the non concordance of treatment with respect to guidelines. Absence of psychotropic treatment in bipolar II patients and inadequate dosage of mood stabilizers were the two other main causes of non concordance with guidelines.

CONCLUSIONS

The factors related to treatment not concordant with guidelines should be further explored to determine appropriate strategies in implementing the use of guidelines in clinical practice.

Treatment strategies according to clinical features in a naturalistic cohort study of bipolar patients: a principal component analysis of lifetime pharmacological and biophysic treatment options

BACKGROUND

The treatment of patients with bipolar disorder (BD) is complex and psychiatrists often have to change treatment strategies. However, available data do not provide information about the most frequent patterns of treatment strategies prescribed in clinical practice and clinical/socio-demographic factors of drugs prescription.

OBJECTIVE

The aims of this study were: (1) to identify specific patterns of life-time treatment strategies in a representative sample of bipolar patients; (2) to assess consistency with guidelines recommendations; and (3) to investigate clinical/socio-demographic of patients.

METHODS

Six-hundred and four BD I and II out-patients were enrolled in a naturalistic cohort study at the Barcelona Bipolar Disorders Program, in a cross-sectional analysis. A principal component analysis was applied to group psychotropic drugs into fewer underlying clusters which represent patterns of treatment strategies more frequently adopted in the life-time naturalistic treatment of BD.

RESULTS

Three main factors corresponding to three main prescription patterns were identified, which explained about 60% of cases, namely, Factor 1 (21.1% of common variance), defined the "antimanic stabilisation package" including treatments with antimanic mechanism of action in predominantly manic-psychotic BD I patients; Factor 2 (20.4%), "antidepressive stabilisation package" that grouped predominantly depressed patients, and Factor 3 (16.4%) defined the "anti-bipolar II package", including antidepressant monotherapy in BD II patients with depressive predominant polarity, melancholic features and higher rates of suicide behaviours.

CONCLUSIONS

This study identified three patterns of lifetime treatment strategies in three specific and different groups of naturalistically treated bipolar patients.

Lamotrigine as add-on treatment to lithium and divalproex: lessons learned from a double-blind, placebo-controlled trial in rapid-cycling bipolar disorder

OBJECTIVES

A substantial portion of the morbidity associated with rapid-cycling bipolar disorder (RCBD) stems from refractory depression. This study assessed the antidepressant effects of lamotrigine as compared with placebo when used as add-on therapy for rapid-cycling bipolar depression non-responsive to the combination of lithium plus divalproex.

METHODS

During Phase 1 of this trial, hypomanic, manic, mixed, and/or depressed outpatients (n = 133) aged 18-65 years with DSM-IV RCBD type I or II were initially treated with the open combination of lithium and divalproex for up to 16 weeks. During Phase 2, subjects who did not meet the criteria for stabilization (n = 49) (i.e., remained in or cycled into the depressed phase) were randomly assigned to double-blind, adjunctive lamotrigine (n = 23) or adjunctive placebo (n = 26). The primary endpoint was the mean change in depression symptom severity from the beginning of Phase 2 to the end of Phase 2 (week 12) on the Montgomery-Åsberg Depression Rating Scale (MADRS) total score. Data were analyzed by analysis of covariance with last observation carried forward and a mixed-models analysis.

RESULTS

  During Phase 1, a high rate of study discontinuations occurred due to intolerable side effects (13/133; 10%) and study non-adherence (22/133; 17%). Only 14% (19/133) stabilized on the open combination of lithium and divalproex. Among the 49 (37%) patients randomized to the double-blind adjunctive treatment phase, mean ± standard error change from baseline on the MADRS total score was -8.5 ± 1.7 points for lamotrigine and -9.1 ± 1.5 points for placebo (p = not significant; mixed-models analysis). No significant differences were observed in the rates of response, remission, or bimodal response between lamotrigine and placebo.

CONCLUSIONS

The poor tolerability, lack of efficacy, and high rate of early discontinuation with the combination of lithium and divalproex suggests this regimen was ineffective for the majority of patients with RCBD. Among patients who did not stabilize on lithium and divalproex, the addition of lamotrigine was no more effective than placebo in reducing depression severity. The findings suggest an opportunity for several design modifications to enhance signal detection in future trials of RCBD. The main limitation is the small number of subjects randomized to double-blind treatment.

Surgical approach and outcomes in patients with lithium-associated hyperparathyroidism

BACKGROUND

Patients receiving lithium therapy are at elevated risk of developing hyperparathyroidism. In lithium-associated hyperparathyroidism (LAH), the incidence of multiglandular disease (MGD) is unclear, and the need for routine bilateral cervical exploration remains controversial. Therefore, in LAH patients, surgical approaches, pathologic findings, cure rates, and factors associated with persistent or recurrent disease were investigated.

METHODS

Retrospective analysis of 27 patients with LAH undergoing parathyroidectomy with the intraoperative parathyroid hormone (PTH) assay.

RESULTS

The median postoperative follow-up was 7 months; 17 patients had >6 months follow-up. Cervical exploration was unilateral in 9, bilateral in 18 (3 were converted from unilateral). Sixteen patients (62%) had MGD, 12 with four-gland hyperplasia and 4 with double adenomas. Ten patients (38%) had a single adenoma. Twenty-five (93%) of 27 patients had initially successful surgery. Of the 17 patients with >6 months follow-up, two had persistent disease and two experienced recurrent disease. All patients with a single adenoma remain free of disease. Three (75%) of four patients with persistent/recurrent disease had MGD and were receiving lithium at the time of surgery. Patients with persistent/recurrent disease were older (p = 0.01) and had experienced a longer duration of hypercalcemia (p = 0.04).

CONCLUSIONS

LAH patients have a high incidence of MGD, and bilateral exploration is frequently necessary. With access to the intraoperative PTH assay, it is reasonable to initiate a unilateral approach because many patients will harbor single adenomas and can be reliably rendered normocalcemic. Patients with MGD remain at higher risk of persistent/recurrent disease.

Efficacy of pharmacotherapy in bipolar disorder: a report by the WPA section on pharmacopsychiatry

The current statement is a systematic review of the available data concerning the efficacy of medication treatment of bipolar disorder (BP). A systematic MEDLINE search was made concerning the treatment of BP (RCTs) with the names of treatment options as keywords. The search was updated on 10 March 2012. The literature suggests that lithium, first and second generation antipsychotics and valproate and carbamazepine are efficacious in the treatment of acute mania. Quetiapine and the olanzapine-fluoxetine combination are also efficacious for treating bipolar depression. Antidepressants should only be used in combination with an antimanic agent, because they can induce switching to mania/hypomania/mixed states/rapid cycling when utilized as monotherapy. Lithium, olanzapine, quetiapine and aripiprazole are efficacious during the maintenance phase. Lamotrigine is efficacious in the prevention of depression, and it remains to be clarified whether it is also efficacious for mania. There is some evidence on the efficacy of psychosocial interventions as an adjunctive treatment to medication. Electroconvulsive therapy is an option for refractory patients. In acute manic patients who are partial responders to lithium/valproate/carbamazepine, adding an antipsychotic is a reasonable choice. The combination with best data in acute bipolar depression is lithium plus lamotrigine. Patients stabilized on combination treatment might do worse if shifted to monotherapy during maintenance, and patients could benefit with add-on treatment with olanzapine, valproate, an antidepressant, or lamotrigine, depending on the index acute phase. A variety of treatment options for BP are available today, but still unmet needs are huge. Combination therapy may improve the treatment outcome but it also carries more side-effect burden. Further research is necessary as well as the development of better guidelines and algorithms for the step-by-step rational treatment.

Maintenance therapies in bipolar disorders

OBJECTIVE

Bipolar disorder is an inherently recurrent disorder, requiring maintenance preventive treatments in the vast majority of patients. The authors review the data on maintenance treatments in bipolar disorder, highlighting the controlled trial literature.

METHODS

Literature review using PubMed, Medline, and a hand search of relevant literature.

RESULTS

Over the last decade, a number of effective maintenance treatments for bipolar disorder have been developed with an evidence base for second-generation antipsychotics and some anticonvulsants. Increasing numbers of patients, therefore, are appropriately treated with multiple medications as a maintenance regimen. For some medications, maintenance treatment has been demonstrated in randomized controlled trials for both monotherapy and in combination with other mood stabilizers. Lithium continues as our oldest well-established maintenance treatment in bipolar disorder with somewhat better efficacy in preventing mania than depression. Lamotrigine, olanzapine, and quetiapine have bimodal efficacy in preventing both mania and depression, although lamotrigine's efficacy is more robust in preventing depression and olanzapine's efficacy is greater in preventing mania. Aripiprazole, ziprasidone, and risperidone long-acting injection all prevent mania, but not depression. Less controlled investigations have suggested some evidence of maintenance mood stabilization with carbamazepine, oxcarbazepine, and adjunctive psychotherapy.

CONCLUSIONS

Despite the number of agents with demonstrated efficacy as maintenance treatments in bipolar disorder, optimal treatment regimens are still a combination of evidence-based therapy in combination with individualized creative treatment algorithms.

Prescribing trends in bipolar disorder: cohort study in the United Kingdom THIN primary care database 1995-2009

OBJECTIVES

To determine changes in prescribing patterns in primary care of antipsychotic and mood stabiliser medication in a representative sample of patients with bipolar disorder in the United Kingdom over a fifteen year period and association with socio-demographic factors.

METHODS

We identified 4700 patients in the Health Improvement Network (THIN) primary care database, who had received treatment for bipolar disorder between 1995 and 2009. The proportion of time for which each individual was prescribed a particular medication was studied, along with variation by sex, age and social depravation status (quintiles of Townsend scores). The number of drugs an individual was taking within a particular year was also examined.

RESULTS

In 1995, 40.6% of patients with bipolar disorder were prescribed a psychotropic medication at least twice. By 2009 this had increased to 78.5% of patients. Valproate registered with the greatest increase in use (22.7%) followed by olanzapine (15.7%) and quetiapine (9.9%). There were differences by age and sex; with young (18-30 year old) women having the biggest increase in proportion of time on medication. There were no differences by social deprivation status. By 2009, 34.2% of women of childbearing age were treated with valproate.

CONCLUSIONS

Lithium use overall remained relatively constant, whilst second generation antipsychotic and valproate use increased dramatically. Changes in prescribing practice preceded published trial evidence, especially with the use of second generation antipsychotics, perhaps with inferences being made from treatment of schizophrenia and use of first generation antipsychotics. Women of childbearing age were prescribed valproate frequently, against best advice.

Drug prescription in Italian Residential Facilities

Aims — To investigate in a representative national sample (N=2,962) of patients living in Residential Facilities (RFs) patterns of polypharmacy as well as related variables, association between diagnoses and therapeutic patterns, and the rate of adverse events. Methods — Structured interviews focusing on each patient were conducted by trained research assistants with the manager and staff of each RF. Patients were rated with the HoNOS and the SOFAS, and comprehensive information about their sociodemographic and clinical status, and their pharmacological regimes were collected. Results — Conventional antipsychotics and second-generation antipsychotics were prescribed to 65% and 43% of the sample, respectively. Benzodiazepines were prescribed to two-thirds of the sample, while antidepressants were the least-used class of psychotropics. Polypharmacy was common: on average, each treated patient was taking 2.7 drugs (±1.1); antipsychotic polypharmacy was also common. Many prescriptions were loosely related to specific diagnoses. Antiparkinsonianian drugs were prescribed to approximately 1/4 of the sample. Mild or severe adverse events in the previous month were reported for 9.9% and 1.4% of the sample, respectively. About 15% of patients suffered from tardive dyskinesia. Conclusions — Psychotropic drug prescription patterns for severe patients living in RFs are only sometimes satisfactory and offer the opportunity of improvement. Specific actions are required to improve prescription patterns for severe patients in RFs.

Declaration of Interest: in the past two years GdG has received two speaker fees from Janssen-Cilag and from Eli Lilly; GS has received one speaker fee from Solvay. RM, AP, SF and RT have received no fees or other financial support from pharmaceutical companies.

Class effect of pharmacotherapy in bipolar disorder: fact or misbelief?

BACKGROUND

Anecdotal reports suggests that most clinicians treat medications as belonging to a class with regard to all therapeutic indications; this means that the whole 'class' of drugs is considered to possesses a specific therapeutic action. The present article explores the possible existence of a true 'class effect' for agents available for the treatment of bipolar disorder.

METHODS

We reviewed the available treatment data from randomized controlled trials (RCTs) and explored 16 'agent class'/'treatment issue' cases for bipolar disorder. Four classes of agents were examined: first-generation antipsychotics (FGAs), second-generation antipsychotics (SGAs), antiepileptics and antidepressants, with respect to their efficacy on four treatment issues of bipolar disorder (BD) (acute mania, acute bipolar depression, maintenance against mania, maintenance against depression).

RESULTS

From the 16 'agent class'/' treatment issue' cases, only 3 possible class effects were detected, and they all concerned acute mania and antipsychotics. Four effect cases have not been adequately studied (FGAs against acute bipolar depression and in maintenance protection from depression, and antidepressants against acute mania and protection from mania) and they all concern treatment cases with a high risk of switching to the opposite pole, thus research in these areas is poor. There is no 'class effect' at all concerning antiepileptics.

CONCLUSIONS

The available data suggest that a 'class effect' is the exception rather than the rule in the treatment of BD. However, the possible presence of a 'class effect' concept discourages clinicians from continued scientific training and reading. Focused educational intervention might be necessary to change this attitude.

The role of ziprasidone in adjunctive use with lithium or valproate in maintenance treatment of bipolar disorder

OBJECTIVES

This article addresses the clinical role for ziprasidone used adjunctively with a mood stabilizer in maintenance treatment of bipolar disorder. This review also addresses the strengths and limitations of design features in adjunctive studies of second-generation antipsychotic drugs added to mood stabilizers.

METHODS

The principal study relevant to this review enrolled subjects who were ≥18 years of age, experiencing a recent or current manic or mixed bipolar I episode, with at least moderately severe current manic symptoms. To meet criteria for randomization to 6 months maintenance treatment, patients had to have failed a short course of treatment with either lithium or valproate and achieved benefit with added ziprasidone for 8 consecutive weeks.

RESULTS

Time to intervention for a new mood episode as well as time to discontinuation for any reason was significantly longer with adjunctive ziprasidone treatment than with monotherapy treatment with mood stabilizer. Three dosages of ziprasidone augmentation were studied. Patients treated with 120 mg/day had better efficacy and overall outcomes than did patients who received 80 or 160 mg/day of ziprasidone.

CONCLUSIONS

Good evidence exists that adjunctive ziprasidone will likely provide greater overall efficacy coupled with good tolerability for at least a 6-month period than a strategy of continued monotherapy with a mood stabilizer. Changes in open phases of maintenance studies to reduce study enrichment, in study endpoints, and in statistical approaches to analysis of data are warranted.

Improving the design of maintenance studies for bipolar disorder

BACKGROUND

In contrast to the trial design of acute mania studies, there is no standard design for bipolar maintenance studies. Over the past 15 years, the design of monotherapy maintenance studies in bipolar disorder has evolved significantly, but recent study designs continue to differ in important ways.

SCOPE

We reviewed the design of recent controlled bipolar maintenance studies, using PubMed, from August 2006 to August 2009, examining the strengths and weaknesses of different study design features.

FINDINGS

Design differences are sufficiently important that the disparate results across maintenance studies may reflect either true differences in medication efficacy or the effects of these design differences on outcome. Design elements such as recent episode polarity, stabilization criteria, using enriched versus nonenriched samples, length of stabilization before randomization, length of experimental phase, and recurrence outcome criteria are critical factors that differ widely across studies and likely play a role in study outcome.

CONCLUSIONS

As consensus for trial designs for bipolar maintenance therapy is developed, it will be easier to develop algorithms for maintenance treatment based on results from studies as opposed to clinical opinions.

Level of response and safety of pharmacological monotherapy in the treatment of acute bipolar I disorder phases: a systematic review and meta-analysis

In recent years, combinations of pharmacological treatments have become common for the treatment of bipolar disorder type I (BP I); however, this practice is usually not evidence-based and rarely considers monotherapy drug regimen (MDR) as an option in the treatment of acute phases of BP I. Therefore, we evaluated comparative data of commonly prescribed MDRs for both manic and depressive phases of BP I. Medline, PsycINFO, EMBASE, the Cochrane Library, the ClinicalStudyResults.org and other data sources were searched from 1949 to March 2009 for placebo and active controlled randomized clinical trials (RCTs). Risk ratios (RRs) for response, remission, and discontinuation rates due to adverse events (AEs), lack of efficacy, or discontinuation due to any cause, and the number needed to treat or harm (NNT or NNH) were calculated for each medication individually and for all evaluable trials combined. The authors included 31 RCTs in the analyses comparing a MDR with placebo or with active treatment for acute mania, and 9 RCTs comparing a MDR with placebo or with active treatment for bipolar depression. According to the collected evidence, most of the MDRs when compared to placebo showed significant response and remission rates in acute mania. In the case of bipolar depression only quetiapine and, to a lesser extent, olanzapine showed efficacy as MDR. Overall, MDRs were well tolerated with low discontinuation rates due to any cause or AE, although AE profiles differed among treatments. We concluded that most MDRs were efficacious and safe in the treatment of manic episodes, but very few MDRs have demonstrated being efficacious for bipolar depressive episodes.

Lithium treatment -- moderate dose use study (LiTMUS) for bipolar disorder: rationale and design

BACKGROUND

Recent data indicate that lithium use for bipolar disorder has declined over the last decade and that lithium largely has been replaced with alternate, commercially promoted medications that may or may not result in better outcomes.

PURPOSE

This article describes the rationale and study design of LiTMUS, a multi-site, prospective, randomized clinical trial of outpatients with bipolar disorder. LiTMUS seeks to address whether initiating therapy at lower doses of lithium as part of optimized treatment (OPT, guideline-informed, evidence-based, and personalized pharmacotherapy) improves outcomes and decreases the need for other medication changes across 6 months of therapy.

METHODS

LiTMUS will randomize 284 adults with bipolar disorder (Type I or II) across 6 study sites. The co-primary outcomes are overall illness severity on clinical global improvement scale for bipolar disorder and a novel measure, necessary clinical adjustments. This metric provides a composite that reflects both clinical response and tolerability. Other relevant outcomes include full symptomatic recovery, quality of life, suicidal behaviors, and moderators of suicidality.

RESULTS

As of August 28th, 2009, we have consented 338 patients and randomized 281 for this study.

LIMITATIONS

The potential limitations of the study include an arbitrary definition of 'low, but effective' doses of lithium, lack of a placebo-controlled group, open treatment, and use of a new outcome measure (i.e., necessary clinical adjustments).

CONCLUSION

We expect that this study will inform our understanding of the effectiveness of low to moderate doses of lithium therapy for individuals with bipolar disorder.

Algorithm-driven treatment for bipolar disorder in Korea: Clinical feasibility, efficacy, and safety

Objective. The Korean Medication Algorithm Project for Bipolar Disorder (KMAP-BP 2002) was developed in 2002. The aim of this study was to evaluate the clinical feasibility, efficacy, and safety of implementation of the KMAP-BP 2002 algorithm in clinical situations. Methods. Participating investigators were asked to follow the KMAP-BP 2002 algorithm as much as possible, but they were allowed to change their treatment strategies as they considered necessary. The enrolled patients were followed for 4 months. Results. A total of 126 bipolar patients were consecutively enrolled and 73% were treated according to the KAMP-BP 2002 algorithm. The majority (79%) of manic patients demonstrated a treatment response at the starting step and were thus treated with only one step of the algorithm. An atypical antipsychotic drug was coadministered with a mood stabilizer from the beginning of treatment in almost all manic patients. There was a significant improvement in manic symptoms (F=187.32, P<0.001) over the 4-month testing period. There was no significant increase in side effects at the endpoint. Overall, the investigators were satisfied with implementing the algorithm. Conclusion. These results suggest that the KMAP-BP 2002 algorithm could be implemented effectively and safely in clinical practice.

Venlafaxine versus lithium monotherapy of rapid and non-rapid cycling patients with bipolar II major depressive episode: a randomized, parallel group, open-label trial

BACKGROUND

There is a paucity of controlled clinical data on the best initial therapy for treating patients with bipolar type II (BP II) major depressive episode (MDE). In this analysis, we examined the safety and antidepressant efficacy of short-term venlafaxine versus lithium monotherapy in rapid and non-rapid cycling patients with BP II MDE. We hypothesized that lithium would have superior efficacy to venlafaxine, with fewer syndromal and sub-syndromal hypomanic and mixed mood conversions in the rapid cycling BP II MDE patients.

METHODS

Patients were randomized to monotherapy with either venlafaxine 37.5-375 mg daily or lithium 300-2100 mg daily for 12 weeks. The primary outcome measure was the 28-item Hamilton Depression Rating (HAM-D 28), with embedded 'typical' HAM-D 17 and 'atypical' HAM-D 17-R symptom scores. Secondary outcomes included the Young Mania Rating Scale (YMRS), clinical global impressions severity (CGI/S) and change (CGI/C) ratings, the proportion of responders (with > or =50% reduction in baseline HAM-D score) and remitters (with a final HAM-D score </=8), and the proportion of patients with syndromal and sub-syndromal mood conversions.

RESULTS

Forty-three patients received venlafaxine (12 rapid cycling) and 40 patients received lithium (15 rapid cycling): 48 (57.8%) were women and 69 (82.1%) were Caucasian. Thirty-three patients (39.8%) prematurely discontinued therapy: 11 for lack of efficacy, 13 for adverse events, 2 for non-compliance, and 7 who were lost to follow up. Venlafaxine produced a greater reduction in HAM-D 28 (p=0.001) and HAM-D 17 (p=0.002) scores (versus lithium) that was independent of cycling status (0.358). Venlafaxine also resulted in a higher rate of responders (p=0.021) and remitters (p=0.001) in rapid cycling patients. There was no significant difference in baseline mean YMRS scores, or mean YMRS change scores over time, between rapid and non-rapid cycling patients. Venlafaxine did not result in a higher proportion of mood conversions (versus lithium) in either the rapid or non-rapid cycling patients.

LIMITATIONS

This was a secondary analysis of rapid versus non-rapid cycling BP II MDE patients. The study was originally powered to detect differences in efficacy between treatment conditions, and was not specifically powered to detect differences in efficacy or mood conversion episodes between rapid and non-rapid cycling groups. We used a conservative life-time definition of rapid cycling (i.e., an average > or =4 affective episodes per year). We did not employ a patient-recorded daily chrono-record to identify ultra-short mood conversions. The study used a randomized, parallel group, open-label design.

CONCLUSION

These observations from this exploratory analysis suggest that venlafaxine monotherapy may be more effective than lithium monotherapy, with a similar mood conversion rate, in rapid and non-rapid cycling patients with BP II MDE. These data support prior observations that venlafaxine monotherapy may be effective initial treatment for BP II MDE.

The association between carbamazepine and valproate and adverse cutaneous drug reactions in patients with bipolar disorder: a nested matched case-control study

OBJECTIVE

This study investigated the association between 2 mood stabilizers (carbamazepine and valproate) and other medications (including other anticonvulsants) and the risks of erythema multiforme (EM), Stevens-Johnson syndrome (SJS), and toxic epidermal necrolysis (TEN) among patients with bipolar disorder.

METHODS

Using the data of patients with bipolar disorder between March 1997 and December 2004 from the Psychiatric Inpatient Medical Claims databank, we identified 72 patients with bipolar disorder who had an inpatient or outpatient diagnosis of EM, SJS, or TEN by the International Classification of Diseases, Ninth Revision, Classical Modification code 695.1 and 288 controls with the absence of EM, SJS, or TEN diagnosis who were matched for sex, age, and index day. The use of carbamazepine, valproate, and other medications during the 60 days before the index date of diagnosis of EM, SJS, or TEN were compared.

RESULTS

Results showed that carbamazepine (odds ratio, 3.7; 95% confidence interval, 2.0-6.8) and valproate use (odds ratio, 2.2; 95% confidence interval, 1.2-4.2) significantly predicted EM, SJS, or TEN. Other significant predictors for EM, SJS, or TEN included other anticonvulsants (phenytoin, phenobarbital, and lamotrigine), cephalosporin, some nonsteroid anti-inflammatory drugs (acetic acid derivatives and fenamates [mefenamic acid]), salicylates, and acetaminophen. The most predictive exposures were carbamazepine, valproate, other anticonvulsants, and acetaminophen. We also found that the combination of carbamazepine and acetaminophen further increased the risk for the occurrence of EM, SJS, or TEN. There was no interaction effect from age and sex.

CONCLUSIONS

Our study suggests that carbamazepine and valproate as well increase the risk for EM, SJS, or TEN. We should be especially cautious about the combined use of carbamazepine and acetaminophen.

Effectiveness of antiepileptic drugs for the treatment of bipolar disorder: findings from a systematic review

Bipolar disorder is characterized by chronic and recurrent symptoms including mania, hypomania, and depressive and mixed episodes, with approximately 5.7 million Americans over age 18, or 2.6% of the U.S. population, suffering from the illness. The prevalence of the disorder may be higher due to its chronic and recurrent nature. Individuals with bipolar disorder often first present in general medical settings with depressive symptomatology. Long-term management typically occurs in mental health settings by psychiatrists or other mental health specialists. While there have been major advances in pharmacotherapy for bipolar disorder, evidence-based information on drug effectiveness is not always easily accessible to prescribers in daily practice. Available information has sometimes led to inappropriate use of various classes of drugs, specifically antiepileptic drugs (AEDs), for bipolar disorder. Originally approved in 1993 by the U.S. Food and Drug Administration (FDA) only for adjunctive treatment of partial complex seizures, the manufacturer of gabapentin (Neurontin), an AED, promoted its off-label use for treatment of psychiatric disorders, including bipolar disorder. The efficacy of the drug for this indication had not been demonstrated, nor had the manufacturer sought FDA approval for the indication. In 2004, 50 Attorneys General settled consumer protection claims regarding alleged deceptive off-label marketing practices of Pfizer subsidiary Warner-Lambert. At about the same time, a consortium of State Medicaid agencies funded a drug class review to compare effectiveness and adverse event profiles of AEDs in the treatment of bipolar mood disorder, neuropathic pain, and fibromyalgia. This article presents a summary of the findings from the drug class review related to prescription of the AEDs in bipolar disorder.

Disseminating findings from a drug class review: using best practices to inform prescription of antiepileptic drugs for bipolar disorder

Evidence from drug class reviews is often not accessible to practicing clinicians nor is it presented in a way that allows clinicians to use the information to guide treatment and prescribing decisions. Nevertheless, information from such reviews can be very helpful to clinicians as they evaluate the "evidence" provided to them through marketing strategies implemented, primarily, by the pharmaceutical industry and designed to influence their prescribing behavior. Unfortunately, these marketing strategies can be used to promote the off-label use of drugs that may not be efficacious. One example is the pharmaceutical marketing to promote off-label use of gabapentin (Neurontin) for the treatment of bipolar disorder, the legality of which was later addressed in a major lawsuit by the National Association of Attorneys General. We describe an effort to use counter-marketing strategies to compete with those implemented by the pharmaceutical industry and to help clinicians, principally psychiatrists, make use of available evidence to inform their prescription of antiepileptic drugs (AEDs) in the treatment of bipolar disorder. A growing body of literature describes industry marketing practices designed to influence prescriber behavior. This literature suggests that use of competing approaches involving the same underlying strategies to deliver highly credible information from trusted sources can inform prescriber knowledge and prescribing practice. We describe our use of existing evidence to develop accurate and convincing messages and materials to be disseminated nationally to counter industry misinformation and promote evidence-based prescription of AEDs.

Antidepressant-associated switches from depression to mania in severe bipolar disorder

OBJECTIVES

To determine whether switching from depression to mania is part of the natural history of bipolar illness or results from antidepressant (AD) treatment by examining bipolar patients with psychosis early in their illness course.

METHODS

A multi-facility cohort of 123 first-admission inpatients, aged 15-60 years, with DSM-IV bipolar disorder (BD) with psychotic features, was followed for four years, and 76 individuals experienced at least one episode of depression. Frequency of and risk factors for switches from depression to mania, time to switch, and duration of the subsequent manic episode were examined in relation to AD use (with anti-manic and/or antipsychotic medications).

RESULTS

The 76 respondents experienced 113 depressive episodes. Those prescribed ADs had more depressive episodes and spent more time depressed than non-users. A total of 23 depressive episodes in 17 respondents ended in a manic/hypomanic/mixed episode (20%). The time to switch and duration of the subsequent manic episode were not significantly different for the seven respondents and nine episodes involving AD treatment versus the 10 respondents and 14 episodes without ADs. None of the risk factors (age of onset <or=18 years, childhood psychopathology, depressive first episode, substance abuse at index admission, bipolar family history, type of AD used) was associated with switching.

CONCLUSIONS

In this sample with severe BD, switching from depression to mania was not associated with AD treatment. Respondents who experienced switching appeared to have a more relentless form of BD. In only a few did ADs appear to be responsible for the switch.

Treatment of bipolar disorder: a complex treatment for a multi-faceted disorder

BACKGROUND

Manic-depression or bipolar disorder (BD) is a multi-faceted illness with an inevitably complex treatment.

METHODS

This article summarizes the current status of our knowledge and practice of its treatment.

RESULTS

It is widely accepted that lithium is moderately useful during all phases of bipolar illness and it might possess a specific effectiveness on suicidal prevention. Both first and second generation antipsychotics are widely used and the FDA has approved olanzapine, risperidone, quetiapine, ziprasidone and aripiprazole for the treatment of acute mania. These could also be useful in the treatment of bipolar depression, but only limited data exists so far to support the use of quetiapine monotherapy or the olanzapine-fluoxetine combination. Some, but not all, anticonvulsants possess a broad spectrum of effectiveness, including mixed dysphoric and rapid-cycling forms. Lamotrigine may be effective in the treatment of depression but not mania. Antidepressant use is controversial. Guidelines suggest their cautious use in combination with an antimanic agent, because they are supposed to induce switching to mania or hypomania, mixed episodes and rapid cycling.

CONCLUSION

The first-line psychosocial intervention in BD is psychoeducation, followed by cognitive-behavioral therapy. Other treatment options include Electroconvulsive therapy and transcranial magnetic stimulation. There is a gap between the evidence base, which comes mostly from monotherapy trials, and clinical practice, where complex treatment regimens are the rule.

Anticonvulsants during electroconvulsive therapy: review and recommendations

OBJECTIVES

To review the literature on the concurrent use of electroconvulsive therapy (ECT) and anticonvulsant drugs (AC) and to provide recommendations to guide clinical practice.

METHODS

A MEDLINE search (1985-2006) was performed, using the terms "electroconvulsive therapy," "anticonvulsants," "epilepsy," "carbamazepine," "gabapentin," "lamotrigine," "topiramate," and "valproate," supplemented by manual searches of guidelines and textbooks on ECT.

RESULTS

To date, no prospective, randomized and controlled trials examining outcome and safety of the AC-ECT combination have been published. Existing data are from case reports on the use of ECT for psychiatric conditions that are simultaneously treated with AC, and from case reports of patients treated with ECT and AC for epilepsy or for psychiatric conditions with comorbid epilepsy. Apart from an occasional difficulty in eliciting seizures, no severe adverse effects or complications are reported.

CONCLUSIONS

The literature that is currently available indicates that ECT can be safely and effectively administered to patients treated with various AC. There is, however, no evidence to combine the 2 treatment modalities to augment therapeutic efficacy.

Pharmacokinetics of aripiprazole and concomitant carbamazepine

The objective of this study was to assess the pharmacokinetics of aripiprazole when coadministered with carbamazepine using an open-label sequential treatment design in patients with schizophrenia or schizoaffective disorder. Nine male patients were enrolled and received aripiprazole monotherapy (30 mg once daily) for 14 days, after which aripiprazole steady-state pharmacokinetics were assessed. Subjects were then administered carbamazepine together with aripiprazole for 4 to 6 weeks. The dose of carbamazepine was titrated to produce a trough serum concentration within the range of 8 to 12 mg/L. Aripiprazole pharmacokinetics were then assessed in the presence of carbamazepine. Six patients completed the study as designed. Coadministration with carbamazepine decreased the values of mean peak plasma concentration and area under the plasma concentration-time curve of aripiprazole by 66% and 71%, respectively (P = 0.001 and 0.002, respectively). Similarly, coadministration with carbamazepine decreased the values of mean peak plasma concentration and area under the plasma concentration-time curve over the 24-hour dosing interval of the major active metabolite of aripiprazole, dehydroaripiprazole, by 68% and 69%, respectively (P < 0.001). Both aripiprazole and dehydroaripiprazole are substrates for the cytochrome P-450 3A4 enzyme which is known to be induced by carbamazepine dosed to steady state. Thus, therapeutic doses of carbamazepine had significant effects on the pharmacokinetics of aripiprazole in patients with schizophrenia or schizoaffective disorder. When carbamazepine is added to aripiprazole therapy, aripiprazole dose should be doubled (to 20-30 mg/d). Additional dose increases should be based on clinical evaluation. When carbamazepine is withdrawn from combination therapy, aripiprazole dose should then be reduced.

Thirty years of clinical experience with carbamazepine in the treatment of bipolar illness: principles and practice

Carbamazepine began to be studied in a systematic fashion in the 1970s and became more widely used in the treatment of bipolar disorder in the 1980s. Interest in carbamazepine has been renewed by (i) the recent US FDA approval of a long-acting preparation for the treatment of acute mania; (ii) studies suggesting some efficacy in bipolar depression; and (iii) evidence of prophylactic efficacy in some difficult-to-treat subtypes of bipolar illness. A series of double-blind controlled studies of the drug were conducted at the US National Institute of Mental Health from the mid-1970s to the mid-1990s. This review summarises our experience in the context of the current literature on the clinical efficacy, adverse effects and pharmacokinetic interactions of carbamazepine. Carbamazepine has an important and still evolving place in the treatment of acute mania and long-term prophylaxis. It may be useful in individuals with symptoms that are not responsive to other treatments and in some subtypes of bipolar disorder that are not typically responsive to a more traditional agent such as lithium. These subtypes might include those patients with bipolar II disorder, dysphoric mania, substance abuse co-morbidity, mood incongruent delusions, and a negative family history of bipolar illness in first-degree relatives. In addition, carbamazepine may be useful in patients who do not adequately tolerate other interventions as a result of adverse effects, such as weight gain, tremor, diabetes insipidus or polycystic ovarian syndrome. We review our clinical and research experience with carbamazepine alone and in combination with lithium, valproic acid and other agents in complex combination treatment of bipolar illness. More precise clinical and biological predictors and correlates of individual clinical responsiveness to carbamazepine and other mood stabilisers are eagerly awaited.

Pharmacological treatment of acute mania in psychiatric in-patients between 1994 and 2004

BACKGROUND

In a cross-section approach we investigated prescription practice in acute mania in 63 German, Swiss and Austrian hospitals between 1994 and 2004.

METHODS

Our data were gathered from a large drug safety program (AMSP) within which on two reference days each year all administered drugs are recorded. For the present study, all cases with a primary diagnosis of acute euphoric mania (n=1291) or mixed-state mania (n=143) were identified. Prescription rates from two periods, 1994 to 1999 and 2000 to 2004, were compared.

RESULTS

In euphoric mania, prescription of lithium decreased by about one-fifth (43.3% to 34.5%, p<0.01), while prescription of anticonvulsants increased by one-half (from 40.0% to 60.7%, p<0.001). Administration of atypical antipsychotics more than doubled (18.5% to 43.9%, p<0.001), while use of typical antipsychotics decreased significantly (56.9% to 27.8%, p<0.001). Overall prescription rates of antipsychotics (79.6% vs. 81.6%) and antidepressants (14.0% vs. 15.5%) remained stable, while administration of tranquilizers increased significantly (26.3% to 34.3%, p<0.01). In mixed-state mania, similar trends over time to those seen in euphoric mania were observed for lithium (43.2% to 33.3%), anticonvulsants (50.0% to 69.7%, p<0.05) and tranquilizers (22.7% to 40.4%). Prescription rates of antipsychotics slightly increased (63.6% to 72.7%), while prescription of antidepressants slightly decreased (54.5% to 46.5%). Polypharmacy was a common phenomenon: patients with euphoric mania were treated with a mean number of 2.9+/-1.2 psychotropic agents, and patients with mixed-state mania with 3.3+/-1.5 psychotropic agents. Both groups showed a significant increase over time. Second-generation atypical antipsychotics were adopted quite rapidly for the treatment of acute mania considering the availability of the scientific evidence at that time. Off-label use was a common phenomenon. Deviations from recommended guidelines were found mainly in the use of antidepressant and antipsychotic drugs both in mixed-state and euphoric mania.

CONCLUSIONS

Naturalistic prescription studies like this may encourage a critical scrutiny of clinical treatment habits and may also drive further research thus moderating potential differences between evidence-based knowledge and everyday clinical practice.

Suicidal risk in bipolar I disorder patients and adherence to long-term lithium treatment

OBJECTIVES

Among the well-established treatments for bipolar disorder (BPD), lithium continues to offer an unusually broad spectrum of benefits that may include reduction of suicidal risk.

METHODS

We examined the association of suicidal acts with adherence to long-term lithium maintenance treatment and other potential risk factors in 72 BP I patients followed prospectively for up to 10 years at a Mood Disorders Research Center in Spain.

RESULTS

The observed rates of suicide were 0.143, and of attempts, 2.01%/year, with a 5.2-fold (95% CI: 1.5-18.6) greater risk among patients consistently rated poorly versus highly adherent to lithium prophylaxis (11.4/2.2 acts/100 person-years). Treatment non-adherence was associated with substance abuse, being unmarried, being male, and having more hypomanic-manic illness and hospitalizations. Suicidal risk was higher with prior attempts, more depression and hospitalization, familial mood disorders, and being single and younger, as well as treatment non-adherence, but with neither sex nor substance abuse. In multivariate analysis, suicidal risk was associated with previous suicidality > poor treatment adherence > more depressive episodes > younger age.

CONCLUSIONS

The findings support growing evidence of lower risk of suicidal acts during closely monitored and highly adherent, long-term treatment with lithium and indicate that treatment adherence is a potentially modifiable factor contributing to antisuicidal benefits.

Mood stabilizer prescribing in a Christchurch adolescent sample: does it comply with guidelines?

OBJECTIVE

To determine the level of compliance with official guidelines for prescribing mood stabilizers among adolescents in Christchurch, New Zealand.

METHODS

A retrospective audit of clinical files of patients aged 13-19 years attending inpatient and outpatient services in the Child, Adolescent and Family Service in the Canterbury District catchment area was carried out against set criteria derived from the Ministry of Health Guidelines regarding the use of mood stabilizers (lithium and sodium valproate). A guideline compliance index was also created to measure overall compliance.

RESULTS

Over a period of 3 years beginning from January 2000, we identified 68 episodes of initiation among 58 adolescents. Of those, 91.2% were for indications set in the guidelines. More than half appeared to have been given no information about the medication, and only 61.8% had documented consent. Two-thirds had a full laboratory work-up before initiation. More than one-third had no evidence of communication with general practitioners about being initiated on a mood stabilizer. Overall, only 13.2% were 100% compliant and only 50% were 80% compliant.

CONCLUSION

In general, mood stabilizers were prescribed as indicated, but adherence to the guidelines beyond that appears to fall short of standards set by the guidelines.

Psychotropic drug prescription in a psychiatric university hospital in Germany

A retrospective survey on drug prescription over a 5-year period (1998 to 2003) in 1,540 inpatients in a psychiatric university hospital in Germany was carried out. The aim was to establish a basis for a monitoring of prescription habits and for pharmacoeconomic considerations. It was established that there was only a slight increase in polyvalent drug use between 1998 and 2003. The results are presented in more detail in relation to the diagnosis of organic mental disorders, drug abuse disorders, schizophrenia, mood disorders and personality disorders. Newer atypical antipsychotics, SSRIs and mood stabilizers were increased across diagnoses while lithium and clozapine were prescribed less frequently. The rare occurrence of monotherapy in general might reflect a common trend in psychiatry fostering polydrug use. Studies of this type are biased by the fact that local habits of prescription do not allow generalisation of the findings. Such surveys should be carried out more frequently and simultaneously in different centers. Critical comparisons could help to optimize treatment.

Add-on quetiapine for bipolar depression: a 12-month open-label trial

OBJECTIVES

Bipolar disorder (BD) is a disabling and often chronic condition. Patients with BD suffer from depression at least one-third of the time, but they do not always respond well to conventional mood stabilizers. Attempts to treat them with antidepressants can provoke a switch to mania or increased cycling. Our open-label trial aimed to assess the long-term response of patients with bipolar depression to the addition of quetiapine to their usual treatment. Our study also sought to assess the safety and tolerability of quetiapine in patients with BD.

METHOD

To meet inclusion criteria for the study, patients had a DSM-IV diagnosis of type I or II BD, were aged 18 years and older, currently suffered from depression with a score of > 18 on the Hamilton Depression Rating Scale (HDRS), and had no change in antidepressant use for at least 3 weeks prior to the study. We added quetiapine to patients' medication and attempted to increase the dosage to at least 400 mg daily. Outcome was measured at baseline and once monthly for 12 months on the HDRS, the Young Mania Rating Scale, the Clinical Global Impression Scale (CGI), and the Abnormal Involuntary Movement Scale.

RESULTS

There were 19 patients enrolled in the study (6 men and 13 women), 2 of whom dropped out because they could not tolerate the drug. Seventeen completed at least 2 assessments, and 7 patients completed the full 12-month trial. Data for the 17 patients (that is, last observation carried forward) at 12 months shows HDRS scores reduced from 27.2 to 12.1 and CGI scores reduced from 4.7 to 2.6.

CONCLUSIONS

Quetiapine seems to be helpful to and relatively well tolerated by patients with bipolar depression when it is added to their usual treatment. There is, however, a need for controlled trials.

Treatment-resistant bipolar disorder

Despite the remarkable increase in medications validated as effective in bipolar disorder, treatment is still plagued by inadequate response in acute manic or depressive episodes or in long-term preventive maintenance treatment. Established first-line treatments include lithium, valproate and second-generation antipsychotics (SGAs) in acute mania, and lithium and valproate as maintenance treatments. Recently validated treatments include extended release carbamazapine for acute mania and lamotrigine, olanzapine and aripiprazole as maintenance treatments. For treatment-resistant mania and as maintenance treatments, a number of newer anticonvulsants, and one older one, phenytoin, have shown some promise as effective. However, not all anticonvulsants are effective and each agent needs to be evaluated individually. Combining multiple agents is the most commonly used clinical strategy for treatment resistant bipolar patients despite a relative lack of data supporting its use, except for acute mania (for which lithium or valproate plus an SGA is optimal treatment). Other approaches that may be effective for treatment-resistant patients include high-dose thyroid augmentation, clozapine, calcium channel blockers and electroconvulsive therapy (ECT). Adjunctive psychotherapies show convincing efficacy using a variety of different techniques, most of which include substantial attention to education and enhancing coping strategies. Only recently, bipolar depression has become a topic of serious inquiry with the dominant controversy focusing on the place of antidepressants in the treatment of bipolar depression. Other than mood stabilizers alone or the combination of mood stabilizers and antidepressants, most of the approaches for treatment-resistant bipolar depression are relatively similar to those used in unipolar depression, with the possible exception of a more prominent place for SGAs, prescribed either alone or in combination with antidepressants. Future work in the area needs to explore the treatments commonly used by clinicians with inadequate research support, such as combination therapy and the use of antidepressants as both acute and adjunctive maintenance treatments for bipolar disorder.