Second-generation antipsychotics have largely replaced mood stabilizers for treatment of bipolar disorder

Taeho Greg Rhee

Researchers have observed significant changes in the treatment of bipolar disorder over the past 2 decades, according to study results published in American Journal of Psychiatry.

These changes included second-generation antipsychotics in large measure having supplanted traditional mood stabilizers. Meanwhile, antidepressant prescriptions have persisted despite a lack of evidence for their efficacy in bipolar disorder.

“We initiated this study to see if lithium has been adequately used in the treatment of bipolar disorder,” Taeho Greg Rhee, PhD, MSW, of the department of public health sciences at University of Connecticut School of Medicine, told Healio Psychiatry. “This is important because patients with bipolar disorder are about 20 to 30 times more likely to commit suicide than those without bipolar disorder, and lithium has a protective effect against suicidality. We found that, unfortunately, lithium use has decreased over time, whereas the use of second-generation antipsychotics has increased in the treatment of bipolar disorder.”

According to Rhee and colleagues, because psychiatrists are a major source of care for patients with bipolar disorder, it is important to determine how outpatient psychiatric prescribing practice trends may have changed following regulatory approval of second-generation antipsychotics and how such practices compare with evidence-based guidelines. To do so, the researchers used nationally representative data from the 1997 to 2016 National Ambulatory Medical Care Surveys to examine trends in the use of first- and second-generation antipsychotics, antidepressants and mood stabilizers among psychiatrist visits for which one of the primary diagnoses was bipolar disorder. They identified statistically significant trends, with covariates including primary insurance, race/ethnicity, age and gender, using a logistic regression model.

Results showed that antipsychotic prescriptions increased from 12.4% of outpatients visits for bipolar disorder between 1997 and 2000 to 51.4% between 2013 and 2016 (adjusted OR [aOR] = 5.05; 95% CI, 3.65-7.01). Mood stabilizer use decreased from 62.3% of bipolar disorder visits between 1997 and 2000 to 26.4% between 2013 and 2016 (aOR = 0.18; 95% CI, 0.13-0.27). Antidepressant prescriptions occurred in 47% of bipolar disorder visits between 1997 and 2000 and 57.5% between 2013 and 2016. Moreover, antidepressant prescriptions without a mood stabilizer increased significantly, from 17.9% between 1997 and 2000 to 40.9% between 2013 and 2016 (aOR = 2.88; 95% CI, 2.06-4.03).

“Lithium may have not been a preferred pharmacotherapeutic approach, as it may be associated with stigma (eg, adverse events),” Rhee told Healio Psychiatry. “More longitudinal research is needed to guide evidence-driven practice in the treatment of bipolar disorder.” – by Joe Gramigna

Disclosures: Rhee reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.