Prescription pattern of mood stabilizers for bipolar disorder at a tertiary health care centre in north India

Pharmacoepidemiology and Clinical Correlates of Lithium Treatment for Bipolar Disorder in Asia

BACKGROUND

As clinical practices with lithium salts for patients diagnosed with bipolar disorder (BD) are poorly documented in Asia, we studied the prevalence and clinical correlates of lithium use there to support international comparisons.

METHODS

We conducted a cross-sectional study of use and dosing of lithium salts for BD patients across 13 Asian sites and evaluated bivariate relationships of lithium treatment with clinical correlates followed by multivariate logistic regression modeling.

RESULTS

In a total of 2139 BD participants (52.3% women) of mean age 42.4 years, lithium salts were prescribed in 27.3% of cases overall, varying among regions from 3.20% to 59.5%. Associated with lithium treatment were male sex, presence of euthymia or mild depression, and a history of seasonal mood change. Other mood stabilizers usually were given with lithium, often at relatively high doses. Lithium use was associated with newly emerging and dose-dependent risk of tremors as well as risk of hypothyroidism. We found no significant differences in rates of clinical remission or of suicidal behavior if treatment included lithium or not.

CONCLUSIONS

Study findings clarify current prevalence, dosing, and clinical correlates of lithium treatment for BD in Asia. This information should support clinical decision-making regarding treatment of BD patients and international comparisons of therapeutic practices.

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.

Valproate regulates inositol synthesis by reducing expression of myo-inositol-3-phosphate synthase

Inositol depletion is a hypothesized mechanism of action of mood stabilization drugs used in the treatment of bipolar disorder. It was previously reported that the mood stabilizer valproate (VPA) increased phosphorylation of myo-inositol-3-phosphate synthases (MIPS), the rate limiting enzyme of inositol synthesis. Phosphosites were identified and examination of site-directed mutants suggested that phosphorylation leads to decreased enzymatic activity. In this study, we examined the extent of MIPS phosphorylation in response to VPA and used two interaction screens to identify protein kinases that interact with MIPS. Using an epitope tagged MIPS construct, we determined the fraction of phosphorylated MIPS to be very low (less than 2% of total), and we could not detect phosphorylation of untagged MIPS in response to VPA. In vitro analyses of phosphorylation revealed that putative protein kinases, PKC and CKII, have low specificity toward MIPS. These findings suggest that VPA likely depletes inositol via a mechanism other than MIPS phosphorylation. Consistent with this, mRNA levels of the MIPS-encoding gene INO1 and MIPS protein levels were significantly reduced during the mid-log growth phase in response to VPA treatment. These findings suggest that the mechanism whereby VPA causes inositol depletion is by reducing expression of the rate-limiting enzyme MIPS.

Pathways to mental health consultations: A study from a tertiary care setting in India

BACKGROUND

Research indicates that help seeking for mental health is low and often delayed. Understanding pathways to care is crucial to facilitate mental health referrals and reduce the time to consultation.

METHODS

In the present study, 63 individuals were assessed on illness severity, attitudes towards help-seeking and pathways-to-care.

RESULTS

Multiple pathways for therapy were noted, a delayed-pathway, two-step referral pathway and a direct-pathway. Most prominent pathway was the delayed-pathway. The direct-pathway had least treatment delay, contributed by timely recognition of symptoms by the patient. As first point of contact, patients preferred psychiatrists and popularly sought information about treatment via media.

CONCLUSIONS

There are multiple pathways to consultations, often leading to treatment delay in care received. Timely recognition of symptoms was associated a direct pathway and the least delay. These findings have implications for strengthening routes to mental health specialists at early stages and increasing awareness about treatment available.

Pharmacotherapeutic interventions for bipolar disorder type II: addressing multiple symptoms and approaches with a particular emphasis on strategies in lower and middle-income countries

Introduction: Appropriately managing mental disorders is a growing priority across countries in view of the impact on morbidity and mortality. This includes patients with bipolar disorders (BD). Management of BD is a concern as this is a complex disease with often misdiagnosis, which is a major issue in lower and middle-income countries (LMICs) with typically a limited number of trained personnel and resources. This needs to be addressed.Areas covered: Medicines are the cornerstone of managing patients with Bipolar II across countries including LMICs. The choice of medicines, especially antipsychotics, is important in LMICs with high rates of diabetes and HIV. However, care is currently compromised in LMICs by issues such as the stigma, cultural beliefs, a limited number of trained professionals and high patient co-payments.Expert opinion: Encouragingly, some LMICs have introduced guidelines for patients with BD; however, this is very variable. Strategies for the future include addressing the lack of national guidelines for patients with BD, improving resources for mental disorders including personnel, improving medicine availability and patients' rights, and monitoring prescribing against agreed guidelines. A number of strategies have been identified to improve the treatment of patients with Bipolar II in LMICs, and will be followed up.

Renal microcysts and lithium

OBJECTIVE

To review the relationship between lithium-related renal dysfunction and microcysts.

METHOD

Electronic databases (PubMed and Google Scholar) were queried.

RESULTS

From a total of 12,425 publications, 76 were reviewed.

DISCUSSION

Glomerular renal dysfunction occurs after an average of 20 years of continuous lithium treatment, and the severity is related to the total lithium load as measured by dose and duration. Recently, several reports have highlighted the relationship between renal microcyst formation and significant reductions in glomerular filtration rate. Radiologically visible lithium-related microcysts are usually 1-2 mm and occasionally 3 mm. Smaller cysts, which are impossible to resolve, are probably more common than the visible cysts, based on observations of renal needle biopsies. Increases in the number of microcysts and the space they occupy within kidney volume appear to be related to both the duration of lithium treatment and the reduction in kidney function. The proposed mechanism of microcyst formation is related to the antiapoptotic effect of lithium. Specifically, by preventing renal tubular epithelial cells from undergoing apoptosis as part of the process of normal renal maintenance, lithium may be allowing the inappropriate growth of the surface area of tubules to form invaginations and ultimately cysts. It is proposed that the physical space occupied by these cysts in the limited volume within the renal capsule compromises the function of otherwise healthy renal tissue. Monitoring of kidneys utilizing radiographic imaging may be more sensitive than monitoring laboratory values. Additional research is required to optimize this new monitoring tool.

Prescription patterns of psychotropic medications for the treatment of psychotic disorders in the largest mental health institutions of Uganda

The study describes prescription patterns of psychotropic medications for patients treated for psychosis in psychiatric hospitals of Uganda. A cross-sectional quantitative survey of age, sex, diagnoses, and psychotropic medication of 682 psychiatric inpatients of the 2 national referral hospitals in Uganda was conducted on 1 day in March 2012. The percentage of patients treated with the same substance within the diagnostic categories schizophrenia, bipolar affective disorder, unspecified psychosis, and depressive disorder was calculated. Close to 90% of the patients with conditions diagnosed with any psychotic disorder were treated with first-generation antipsychotic drugs (eg, chlorpromazine, haloperidol, trifluoperazine, and depot fluphenazine). Carbamazepine in combination with first-generation antipsychotics was prescribed frequently (45%) for the treatment of bipolar affective disorder. The use of second-generation antipsychotics, lithium, and valproic acid was exceptional. Patients with depression usually received a combination (63%) of first-generation antipsychotics and antidepressants (fluoxetine or amitriptyline). Benzodiazepines were only infrequently used for patients diagnosed with psychoses. First-generation antipsychotics, antidepressants, and carbamazepine were the most frequently used medications for treatment of psychosis in Uganda. Although lithium and valproic acid were on the essential drug list in Uganda, their use was still infrequent. There is a need to ensure the practical availability of the drugs listed on the essential drug list and to support the implementation of their use in clinical practice.

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.

Pharmacotherapy of Bipolar Affective Disorder: A Hospital based Study from Sub Himalayan Valley of Nepal

INTRODUCTION

In Bipolar disorder the mood of the patients fluctuates between depression and mania. The main objective of the study was to find out the commonest mood stabilizers used for the treatment of Bipolar affective disorders in Western Nepal in hospitalized patients in an actual clinical set up.

METHODS

This was a cross-sectional study which was conducted between October 2009 and September 2010 at Psychiatric ward at Manipal teaching hospital, Pokhara, Nepal, a tertiary care hospital situated in Western Nepal. The diagnosis of the disease was based on ICD-10 (Tenth revision) Classification of mental and Behavioural disorders, Diagnostic Criteria for Research. We calculated odds ratio and their 95% confidence intervals (95% CI). p< 0.05 was considered as statistically significant.

RESULTS

62.1% of the patients were less than 40 yrs, 56.3% were male, 72.4% were unemployed and 75.9% of the patients were having monthly income <10,000/month. As far as ethnicity is concerned 37.9% of the cases were Brahmin and by occupation 29.9% of the patients were students followed by housewife 25.3%, labour 17.2%, retired 13.8% respectively. Drugs and Psychotherapy [OR 1.4, 95% (CI 0.575, 3.4017)] was prescribed in age <40 years as compared to age>40 yrs. Male patients [OR 7.22, 95% (CI 0.862, 60.499)] and [OR 2.353, 95% (CI 0.857, 6.455)] received drugs by trade names and drugs not from the national drug list of Nepal as compared to females. Monthly income <10,000/month and [OR 2.8, 95% (CI 0.742, 10.56)] tendency of receiving drugs by trade names. Among the mood elevators Sodium valproate was the commonest drug to be prescribed in 51/87(58.6%) patients followed by Lithium in 30/87 (34.5%) cases and Carbamazepine in 6/87 (6.9%) cases. Sodium valproate was prescribed at 1,000 mg/day, Lithium was prescribed at 900 mg/day in and Carbamazepine was prescribed at 800 mg/day.

CONCLUSION

Among all the mood elevators Sodium valproate is the commonest drug prescribed for the treatment of bipolar affective disorder, recommended that there is a trend of using newer drugs like sodium valproate rather than the conventional mood stabilizers like Lithium for bipolar affective disorder in Western Development region of Nepal.