A population-based study of the comparative effectiveness of second-generation antipsychotics vs older antimanic agents in bipolar 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.

Advances in the psychopharmacotherapy of bipolar disorder type I

INTRODUCTION

Research into the pharmacologic management of bipolar type I illness continues to progress.

AREAS COVERED

Randomized clinical trials performed with type I bipolar disorder in the years 2015 to August 2020 are reviewed. There are new indications for the use of cariprazine, for bipolar mania and depression, and a long-acting injectable formulation of aripiprazole has also been approved for relapse prevention in bipolar illness. Most of the randomized clinical trials are effectiveness studies.

EXPERT OPINION

Over the 20 years from 1997 through 2016, the use of lithium and other mood stabilizers has declined by 50%, while the use of both second-generation antipsychotics (SGAs) and antidepressants has increased considerably. Over the same time period (1990-2017), disability-adjusted life years (DALYs) increased by 54.4%, from 6.02 million in 1990 to 9.29 million in 2017 which is greater than the 47.74% increase in incidence of the disease, suggesting that the changes in prescribing patterns have not been helpful for our patients. Furthermore, recent effectiveness studies continue to confirm the superiority of lithium and other mood stabilizers in the management of bipolar illness for both psychiatric and medical outcomes, reaffirming their role as foundational treatments in the management of type I bipolar disorder. Clinicians need to reassess their prescribing habits.

Conventional mood stabilizers and/or second-generation antipsychotic drugs in bipolar disorders: A population-based comparison of risk of treatment failure

BACKGROUND

The study compared treatment failure when using three therapeutic strategies in bipolar disorders: (i) mood stabilizers (MSs: lithium, valpromide, divalproate, carbamazepine, lamotrigine) without second-generation antipsychotic (SGAP); (ii) SGAPs (aripiprazole, olanzapine, risperidone, quetiapine) without MS; (iii) combination of MSs and SGAPs.

METHODS

A historical cohort study was conducted using the French national healthcare databases in 20,086 outpatients aged 21+, newly treated with one of the three treatment strategies in 2011-2012, and diagnosed with a bipolar disorder. A composite outcome was based on indicators of treatment failure identified over 12 months: treatment discontinuation, switch or addition, psychiatric hospitalisation, suicide attempt, and death. For each strategy, the cumulative incidence of treatment failure was calculated while adjusting for covariates by propensity score weighting.

RESULTS

A total of 8,225 patients (40.9%) were newly dispensed MSs, 9,342 (46.5%) SGAPs, and 2,519 (12.5%) both MSs and SGAPs. The one-year adjusted cumulative incidence of treatment failure was 75.7% (95%CI 74.9;76.3) in patients using MSs, 75.3% (74.6;76.0) in patients using SGAPs, and 60.5% (58.3;62.6) in patients with the combination. The adjusted difference in incidence for SGAPs compared with MSs was -0.40% (-1.4;0.6 p = 0.4) in the whole population, -2.2% (-3.3; -1.2 p < 0.002) in patients under 65 years and +6.7% (4.1;9.1 p < 0.002) in patients 65 years and over.

LIMITATIONS

Combinations of MSs and SGAPs could not be directly compared with MS or SGAP monotherapies.

CONCLUSIONS

One-year treatment failure was high. Overall, no difference in treatment failure was observed between MS or SGAP strategy but differences might exist depending on age.

Effectiveness of Implementing a Collaborative Chronic Care Model for Clinician Teams on Patient Outcomes and Health Status in Mental Health: A Randomized Clinical Trial

IMPORTANCE

Collaborative chronic care models (CCMs) have extensive randomized clinical trial evidence for effectiveness in serious mental illnesses, but little evidence exists regarding their feasibility or effect in typical practice conditions.

OBJECTIVE

To determine the effectiveness of implementation facilitation in establishing the CCM in mental health teams and the impact on health outcomes of team-treated individuals.

DESIGN, SETTING, AND PARTICIPANTS

This quasi-experimental, randomized stepped-wedge implementation trial was conducted from February 2016 through February 2018, in partnership with the US Department of Veterans Affairs (VA) Office of Mental Health and Suicide Prevention. Nine facilities were enrolled from all VA facilities in the United States to receive CCM implementation support. All veterans (n = 5596) treated by designated outpatient general mental health teams were included for hospitalization analyses, and a randomly selected sample (n = 1050) was identified for health status interviews. Individuals with dementia were excluded. Clinicians (n = 62) at the facilities were surveyed, and site process summaries were rated for concordance with the CCM process. The CCM implementation start time was randomly assigned across 3 waves. Data analysis of this evaluable population was performed from June to September 2018.

INTERVENTIONS

Internal-external facilitation, combining a study-funded external facilitator and a facility-funded internal facilitator working with a designated team for 1 year.

MAIN OUTCOMES AND MEASURES

Facilitation was hypothesized to be associated with improvements in both implementation and intervention outcomes (hybrid type II trial). Implementation outcomes included the clinician Team Development Measure (TDM) and proportion of CCM-concordant team care processes. The study was powered for the primary health outcome, mental component score (MCS). Hospitalization rate was derived from administrative data.

RESULTS

The veteran population (n = 5596) included 881 women (15.7%), and the mean (SD) age was 52.2 (14.5) years. The interviewed sample (n = 1050) was similar but was oversampled for women (n = 210 [20.0%]). Facilitation was associated with improvements in TDM subscales for role clarity (53.4%-68.6%; δ = 15.3; 95% CI, 4.4-26.2; P = .01) and team primacy (50.0%-68.6%; δ = 18.6; 95% CI, 8.3-28.9; P = .001). The percentage of CCM-concordant processes achieved varied, ranging from 44% to 89%. No improvement was seen in veteran self-ratings, including the primary outcome. In post hoc analyses, MCS improved in veterans with 3 or more treated mental health diagnoses compared with others (β = 5.03; 95% CI, 2.24-7.82; P < .001). Mental health hospitalizations demonstrated a robust decrease during facilitation (β = -0.12; 95% CI, -0.16 to -0.07; P < .001); this finding withstood 4 internal validity tests.

CONCLUSIONS AND RELEVANCE

Implementation facilitation that engages clinicians under typical practice conditions can enhance evidence-based team processes; its effect on self-reported overall population health status was negligible, although health status improved for individuals with complex conditions and hospitalization rate declined.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02543840.

The Association Between Psychotropic Drug Use and Fertility Problems Among Male Subjects

Mental disorders affect a high percentage of the general population and are associated with a significant burden. One major component of treatment for mental illnesses is pharmacotherapy. Various psychotropic medications are used in the treatment of psychiatric disorders and these are often associated with a plethora of side effects. The many side effects of psychotropic drugs can severely impair patients' quality of life and decrease their adherence to treatment. Among the relatively neglected and less-studied potential side effects of psychotropic drugs are impairment of sperm parameters and fertility problems among male patients. This article summarizes the data with regard to the effects of 6 widely used psychotropic drugs-lithium, valproate, haloperidol, olanzapine, imipramine, and fluoxetine-on sexual function and sperm parameters in male subjects. In general, the reviewed data suggest that these medications can be associated with sexual function problems and negative effects on sperm parameters among male subjects. It is important to note that most of the data are based on preclinical studies and nonrandomized clinical trials with relatively small sample sizes, so that it is not possible to draw unequivocal conclusions with regard to the clinical relevance of the findings. Prospective, randomized clinical trials are necessary to elucidate the effects of psychotropic drugs on men's sperm parameters and fertility indices per se.

Comprehensive comparison of monotherapies for psychiatric hospitalization risk in bipolar disorders

OBJECTIVES

This study compared 29 drugs for risk of psychiatric hospitalization in bipolar disorders, addressing the evidence gap on the >50 drugs used by US patients for treatment.

METHODS

The Truven Health Analytics MarketScan^® database was used to identify 190 894 individuals with bipolar or schizoaffective disorder who filled a prescription for one of 29 drugs of interest: lithium, first- or second-generation antipsychotics, mood-stabilizing anticonvulsants, and antidepressants. Competing risks regression survival analysis was used to compare drugs for risk of psychiatric hospitalization, adjusting for patient age, sex, comorbidities, and pretreatment medications. Other competing risks were ending monotherapy and non-psychiatric hospitalization.

RESULTS

Three drugs were associated with significantly lower risk of psychiatric hospitalization than lithium: valproate (relative risk [RR] = 0.80, P = 3.20 × 10^-4 ), aripiprazole (RR = 0.80, P = 3.50 × 10^-4 ), and bupropion (RR = 0.80, P = 2.80 × 10^-4 ). Eight drugs were associated with significantly higher risk of psychiatric hospitalization: haloperidol (RR = 1.57, P = 9.40 × 10^-4 ), clozapine (RR = 1.52, P = .017), fluoxetine (RR = 1.17, P = 3.70 × 10^-3 ), sertraline (RR = 1.17, P = 3.20 × 10^-3 ), citalopram (RR = 1.14, P = .013), duloxetine (RR = 1.24, P = 5.10 × 10^-4 ), venlafaxine (RR = 1.33; P = 1.00 × 10^-6 ), and ziprasidone (RR = 1.25; P = 6.20 × 10^-3 ).

CONCLUSIONS

This largest reported retrospective observational study on bipolar disorders pharmacotherapy to date demonstrates that the majority of patients end monotherapy within 2 months after treatment start. The risk of psychiatric hospitalization varied almost two-fold across individual medications. The data add to the evidence favoring lithium and mood stabilizer use in short-term bipolar disorder management. The findings that the dopaminergic drugs aripiprazole and bupropion had better outcomes than other members of their respective classes and that antidepressant outcomes may vary by baseline mood polarity merit further investigation.

Long-acting injectable antipsychotics as maintenance treatments for bipolar disorder-A critical review of the evidence

OBJECTIVES

The maintenance phase of bipolar disorder is arguably the most important. The aim of management during this time is to maintain wellness and prevent future episodes of illness. Medication is often the mainstay of treatment during this phase, but adherence to treatment is a significant problem. In recent years, long-acting injectable (LAI) solutions have been proposed, but these too have limitations. This paper discusses the options that are currently available and critically appraises the effectiveness of this strategy.

METHOD

The authors reviewed the small number of open-label and randomised studies on LAI medications in bipolar disorder and evaluated the efficacy and safety of these medications.

RESULTS

The studies reviewed show benefit of LAIs for the management of bipolar disorder but have several key limitations to the generalisability of findings to routine practice.

CONCLUSIONS

LAIs have an emerging role in the management of bipolar disorder and, although it is not without limitations, this strategy addresses some issues of long-term treatment and medication. Patients with bipolar disorder that are non-adherent or have an unstable illness with a predilection towards mania are possibly better suited to the use of LAIs, though more research is required to fully assess the effectiveness of this approach.

Systematic literature review on patterns of pharmacological treatment and adherence among patients with bipolar disorder type I in the USA

BACKGROUND

Bipolar disorder type I (BD-I) is a chronic condition characterized by mania episodes followed by syndromic recovery periods, usually permeated by depressive symptoma-tology and recurring acute manic episodes. It requires long-term pharmacological treatment; thus, it is critical to understand the patterns of drug therapy use and medication compliance to better plan health care policies and needs. This systematic literature review aims to study these data among patients with BD-I in the USA, focusing on medications to treat mania.

METHODS

Articles published in the last 10 years to October 2016 were searched on MEDLINE and Embase. Studies on patterns of drug therapy, concordance of prescription with clinical practice guidelines, and adherence and persistence with pharmacological treatments for BD-I in the USA under observational conditions, with focus on treatments for mania, were selected.

RESULTS

Treatment prevalence for BD-I is low in the USA, with the most current study showing a 46% 12-month rate. There is a lack of studies addressing the use of long-acting injectable (LAI) antipsychotics. Second-generation antipsychotics (SGAs) have been used by nearly all patients receiving oral antipsychotics since the 2000s. However, 30%-60% of individuals with BD do not receive appropriate treatment, and adherence to oral therapies is poor, with medication possession ratios ≥80% seen in only approximately 60% of patients. For persistence rates, results suggest that treatment duration is short for a condition with recommendation for at least 6 months of maintenance therapy. Literature indicates that LAI SGAs may be related to better adherence and persistence.

CONCLUSION

There is a need for studies addressing specifically patterns of therapy and adherence to pharmacological treatment in BD-I patients in the USA to better understand the value of current standards, and an urgent need to improve the rates of adherence and persistence to BD-I pharmacotherapy and to increase the understanding of LAI SGAs' potential to address this issue.

Deficiency of Shank2 causes mania-like behavior that responds to mood stabilizers

Genetic defects in the synaptic scaffolding protein gene, SHANK2, are linked to a variety of neuropsychiatric disorders, including autism spectrum disorders, schizophrenia, intellectual disability, and bipolar disorder, but the molecular mechanisms underlying the pleotropic effects of SHANK2 mutations are poorly understood. We generated and characterized a line of Shank2 mutant mice by deleting exon 24 (Δe24). Shank2Δe24-/- mice engage in significantly increased locomotor activity, display abnormal reward-seeking behavior, are anhedonic, have perturbations in circadian rhythms, and show deficits in social and cognitive behaviors. While these phenotypes recapitulate the pleotropic behaviors associated with human SHANK2-related disorders, major behavioral features in these mice are reminiscent of bipolar disorder. For instance, their hyperactivity was augmented with amphetamine but was normalized with the mood stabilizers lithium and valproate. Shank2 deficiency limited to the forebrain recapitulated the bipolar mania phenotype. The composition and functions of NMDA and AMPA receptors were altered at Shank2-deficient synapses, hinting toward the mechanism underlying these behavioral abnormalities. Human genetic findings support construct validity, and the behavioral features in Shank2 Δe24 mice support face and predictive validities of this model for bipolar mania. Further genetic studies to understand the contribution of SHANK2 deficiencies in bipolar disorder are warranted.