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Lithium superior to divalproex for mania in geriatric bipolar I disorder

Lithium and divalproex were both well-tolerated and effective for mania in older adults with bipolar I disorder; however, lithium was associated with greater reduction in mania at 9 weeks.

“In late life, bipolar disorder is associated with high utilization of mental health and other medical services, persisting disability, increased mortality, and increased risk for suicide and dementia,” Robert C. Young, MD, of Weill Cornell Medicine, New York, and colleagues wrote. “Despite the increasing number of older adults with bipolar disorder, evidence that can guide their treatment is strikingly limited.”

To compare efficacy and tolerability of lithium carbonate and divalproex for mania in bipolar I disorder in older adults, researchers conducted a randomized, double-blind controlled trial among 224 individuals aged 60 years and older with bipolar I disorder who presented with a manic, hypomanic, or mixed episode. Study participants were randomly assigned to receive lithium or divalproex for 9 weeks. Participants with inadequate response after 3 weeks received open adjunctive risperidone.

Attrition rates were similar for lithium and divalproex groups, at 14% and 18% at week 3 and 51% and 44% at week 9.

Sedation did not significantly differ between treatment groups.

Tremor was more common among participants who received lithium.

Target concentrations were achieved by 57% of participants who received lithium and 56% who received divalproex.

Participants who received lithium exhibited greater improvement in Young Mania Rating Scale scores, with a 3.9 change in score at 9 weeks.

Response rates were comparable between lithium and divalproex groups at 9 weeks (79% vs. 73%).

Overall, 17% of participants in the lithium group and 14% of those in the divalproex group received adjunctive risperidone.

“Our main findings, if confirmed, have implications for geriatric practice and investigation,” the researchers wrote. “Treatment with lithium or divalproex with conservative serum concentration targets, combined with limited use of rescue and adjunctive medications, was tolerated by older patients with mania, and it benefited a substantial proportion of them. These results suggest that treatment guidelines for older persons with bipolar disorder should emphasize greater use of lithium and less exposure to antipsychotics.” – by Amanda Oldt

Disclosures : Young reports he receives support from AstraZeneca. Please see the full study for a list of relevant financial disclosures.