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Published Online: 1 January 2013

Lithium Treatment Moderate-Dose Use Study (LiTMUS) for Bipolar Disorder: A Randomized Comparative Effectiveness Trial of Optimized Personalized Treatment With and Without Lithium

Abstract

Personalized treatment of bipolar I or II disorder that includes lithium does not appear to be superior to individualized care using other evidence-based treatments. In a 6-month comparison study, the overall remission rate was 27%, with no difference in remission or adverse events between the lithium and nonlithium groups.

Abstract

Objective

Lithium salts, once the mainstay of therapy for bipolar disorder, have tolerability issues at a higher dosage that often limit adherence. The authors investigated the comparative effectiveness of more tolerable dosages of lithium as part of optimized personalized treatment (OPT).

Method

The authors randomly assigned 283 bipolar disorder outpatients to 6 months of open, flexible, moderate dosages of lithium plus OPT or to 6 months of OPT alone. The primary outcome measures were the Clinical Global Impression Scale for Bipolar Disorder–Severity (CGI-BP-S) and “necessary clinical adjustments” (medication adjustments per month). Secondary outcome measures included mood symptoms and functioning. The authors also assessed sustained remission (defined as a CGI-BP-S score ≤2 for 2 months) and treatment with second-generation antipsychotics. The authors hypothesized that lithium plus OPT would result in greater clinical improvement and fewer necessary clinical adjustments.

Results

The authors observed no statistically significant advantage of lithium plus OPT on CGI-BP-S scores, necessary clinical adjustments, or proportion with sustained remission. Both groups had similar outcomes across secondary clinical and functional measures. Fewer patients in the lithium-plus-OPT group received second-generation antipsychotics compared with the OPT-only group (48.3% and 62.5%, respectively).

Conclusions

In this pragmatic comparative effectiveness study, a moderate but tolerated dosage of lithium plus OPT conferred no symptomatic advantage when compared with OPT alone, but the lithium-plus-OPT group had less exposure to second-generation antipsychotics. Only about one-quarter of patients in both groups achieved sustained remission of symptoms. These findings highlight the persistent and chronic nature of bipolar disorder as well as the magnitude of unmet needs in its treatment.

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Information & Authors

Information

Published In

Go to American Journal of Psychiatry
Go to American Journal of Psychiatry
American Journal of Psychiatry
Pages: 102 - 110
PubMed: 23288387

History

Received: 6 June 2012
Revision received: 12 July 2012
Accepted: 2 August 2012
Published online: 1 January 2013
Published in print: January 2013

Authors

Affiliations

Andrew A. Nierenberg, M.D.
From Massachusetts General Hospital, Boston; the University of Pittsburgh School of Medicine; the University of Texas Health Science Center, San Antonio; the University of Pennsylvania School of Medicine, Philadelphia; Stanford University, Stanford, Calif.; Weill Cornell Medical College, New York; Mount Sinai School of Medicine, New York; Harvard Clinical Research Institute, Boston; NIMH, Rockville, Md.; and Case Western Reserve University School of Medicine, Cleveland.
Edward S. Friedman, M.D.
From Massachusetts General Hospital, Boston; the University of Pittsburgh School of Medicine; the University of Texas Health Science Center, San Antonio; the University of Pennsylvania School of Medicine, Philadelphia; Stanford University, Stanford, Calif.; Weill Cornell Medical College, New York; Mount Sinai School of Medicine, New York; Harvard Clinical Research Institute, Boston; NIMH, Rockville, Md.; and Case Western Reserve University School of Medicine, Cleveland.
Charles L. Bowden, M.D.
From Massachusetts General Hospital, Boston; the University of Pittsburgh School of Medicine; the University of Texas Health Science Center, San Antonio; the University of Pennsylvania School of Medicine, Philadelphia; Stanford University, Stanford, Calif.; Weill Cornell Medical College, New York; Mount Sinai School of Medicine, New York; Harvard Clinical Research Institute, Boston; NIMH, Rockville, Md.; and Case Western Reserve University School of Medicine, Cleveland.
Louisa G. Sylvia, Ph.D.
From Massachusetts General Hospital, Boston; the University of Pittsburgh School of Medicine; the University of Texas Health Science Center, San Antonio; the University of Pennsylvania School of Medicine, Philadelphia; Stanford University, Stanford, Calif.; Weill Cornell Medical College, New York; Mount Sinai School of Medicine, New York; Harvard Clinical Research Institute, Boston; NIMH, Rockville, Md.; and Case Western Reserve University School of Medicine, Cleveland.
Michael E. Thase, M.D.
From Massachusetts General Hospital, Boston; the University of Pittsburgh School of Medicine; the University of Texas Health Science Center, San Antonio; the University of Pennsylvania School of Medicine, Philadelphia; Stanford University, Stanford, Calif.; Weill Cornell Medical College, New York; Mount Sinai School of Medicine, New York; Harvard Clinical Research Institute, Boston; NIMH, Rockville, Md.; and Case Western Reserve University School of Medicine, Cleveland.
Terence Ketter, M.D.
From Massachusetts General Hospital, Boston; the University of Pittsburgh School of Medicine; the University of Texas Health Science Center, San Antonio; the University of Pennsylvania School of Medicine, Philadelphia; Stanford University, Stanford, Calif.; Weill Cornell Medical College, New York; Mount Sinai School of Medicine, New York; Harvard Clinical Research Institute, Boston; NIMH, Rockville, Md.; and Case Western Reserve University School of Medicine, Cleveland.
Michael J. Ostacher, M.D., M.P.H.
From Massachusetts General Hospital, Boston; the University of Pittsburgh School of Medicine; the University of Texas Health Science Center, San Antonio; the University of Pennsylvania School of Medicine, Philadelphia; Stanford University, Stanford, Calif.; Weill Cornell Medical College, New York; Mount Sinai School of Medicine, New York; Harvard Clinical Research Institute, Boston; NIMH, Rockville, Md.; and Case Western Reserve University School of Medicine, Cleveland.
Andrew C. Leon, Ph.D.
From Massachusetts General Hospital, Boston; the University of Pittsburgh School of Medicine; the University of Texas Health Science Center, San Antonio; the University of Pennsylvania School of Medicine, Philadelphia; Stanford University, Stanford, Calif.; Weill Cornell Medical College, New York; Mount Sinai School of Medicine, New York; Harvard Clinical Research Institute, Boston; NIMH, Rockville, Md.; and Case Western Reserve University School of Medicine, Cleveland.
Noreen Reilly-Harrington, Ph.D.
From Massachusetts General Hospital, Boston; the University of Pittsburgh School of Medicine; the University of Texas Health Science Center, San Antonio; the University of Pennsylvania School of Medicine, Philadelphia; Stanford University, Stanford, Calif.; Weill Cornell Medical College, New York; Mount Sinai School of Medicine, New York; Harvard Clinical Research Institute, Boston; NIMH, Rockville, Md.; and Case Western Reserve University School of Medicine, Cleveland.
Dan V. Iosifescu, M.D.
From Massachusetts General Hospital, Boston; the University of Pittsburgh School of Medicine; the University of Texas Health Science Center, San Antonio; the University of Pennsylvania School of Medicine, Philadelphia; Stanford University, Stanford, Calif.; Weill Cornell Medical College, New York; Mount Sinai School of Medicine, New York; Harvard Clinical Research Institute, Boston; NIMH, Rockville, Md.; and Case Western Reserve University School of Medicine, Cleveland.
Michael Pencina, Ph.D.
From Massachusetts General Hospital, Boston; the University of Pittsburgh School of Medicine; the University of Texas Health Science Center, San Antonio; the University of Pennsylvania School of Medicine, Philadelphia; Stanford University, Stanford, Calif.; Weill Cornell Medical College, New York; Mount Sinai School of Medicine, New York; Harvard Clinical Research Institute, Boston; NIMH, Rockville, Md.; and Case Western Reserve University School of Medicine, Cleveland.
Joanne B. Severe, M.S.
From Massachusetts General Hospital, Boston; the University of Pittsburgh School of Medicine; the University of Texas Health Science Center, San Antonio; the University of Pennsylvania School of Medicine, Philadelphia; Stanford University, Stanford, Calif.; Weill Cornell Medical College, New York; Mount Sinai School of Medicine, New York; Harvard Clinical Research Institute, Boston; NIMH, Rockville, Md.; and Case Western Reserve University School of Medicine, Cleveland.
Joseph R. Calabrese, M.D.
From Massachusetts General Hospital, Boston; the University of Pittsburgh School of Medicine; the University of Texas Health Science Center, San Antonio; the University of Pennsylvania School of Medicine, Philadelphia; Stanford University, Stanford, Calif.; Weill Cornell Medical College, New York; Mount Sinai School of Medicine, New York; Harvard Clinical Research Institute, Boston; NIMH, Rockville, Md.; and Case Western Reserve University School of Medicine, Cleveland.

Notes

Address correspondence to Dr. Nierenberg ([email protected]).

Funding Information

Dr. Nierenberg has received consulting fees, advisory board fees, research support, or speakers honoraria from American Drug Utilization Review, American Professional Society of ADHD and Related Disorders, American Psychiatric Association, American Society for Clinical Psychopharmacology, Appliance Computing (Mindsite), AstraZeneca, Basliea, Baystate Medical Center, Belvoir Publishing, Brain Cells, Brandeis University, Bristol-Myers Squibb, Columbia University, Corcept, Dainippon Sumitomo, Eli Lilly, EpiQ, Forest Pharmaceuticals, Hillside Hospital, IMEDEX, International Society for Bipolar Disorders, Johnson & Johnson, MJ Consulting, Medscape, MBL Publishing, New York State, NIMH, Novartis, PamLabs, Pfizer, PGx Health, Physicians Postgraduate Press, Ridge Diagnostics, Schering-Plough, SciMed, Shire, SUNY Buffalo, Takeda/Lundbeck, Targacept, Teva Pharmaceuticals, University of Texas Southwestern Dallas, University of Wisconsin, and University of Pisa; has consulted through the MGH Clinical Trials Network and Institute for Brain Cells, Dianippon Sumitomo/Sepracor, Johnson & Johnson, Labopharm, Merck, Methylation Science, Novartis, PGx Health, Schering-Plough, Shire, Targacept, and Takeda/Lundbeck Pharmaceuticals; and owns stock options in Appliance Computing and Brain Cells. Through Massachusetts General Hospital, Dr. Nierenberg is named for copyrights to the Clinical Positive Affect Scale and the MGH Structured Clinical Interview for the Montgomery-Åsberg Depression Scale exclusively licensed to the MGH Clinical Trials Network and Institute. Dr. Nierenberg is a presenter for the Massachusetts General Hospital Psychiatry Academy (MGHPA). The education programs conducted by the MGHPA were supported through Independent Medical Education grants from Astra Zeneca, Bristol-Myers Squibb, Eli Lilly, and Janssen Pharmaceuticals. Dr. Friedman has received consulting fees, advisory board fees, research support, royalties, or speakers honoraria from Aspect Medical Systems, AstraZeneca, Bristol-Myers Squibb, Cyberonics, Indevus, Medtronics, the NIMH Agency for Healthcare Research and Quality, NorthStar/St. Jude Medical, Novartis, Respironics, Sanofi-Aventis, Springer, and Wyeth-Ayerst. Dr. Bowden has received consulting fees, advisory board fees, research support, or speakers honoraria from Bristol-Myers Squibb, Johnson & Johnson, Merck Pfizer, NIMH, Repligen, and Sanofi-Aventis. Dr. Sylvia has received consulting fees from Bracket Global and Clintara, was a shareholder for Concordant Rater Systems, has received royalties from New Harbinger Publisher, and has presented for the MGHPA. Dr. Thase has received consulting fees, advisory board fees, research support, or speakers honoraria from AstraZeneca, Bristol-Myers Squibb, Dey Pharma, Eli Lilly, Forest Pharmaceuticals, Gerson Lehman Group, GlaxoSmithKline, Guidepoint Global, H. Lundbeck A/S, MedAvante, Merck, Neuronetics, the NIMH Agency for Healthcare Research Quality, Novartis, Ortho-McNeil Pharmaceuticals, Otsuka, PamLab, Pfizer, Schering-Plough, Sepracor, Shire, Supernus Pharmaceuticals, Takeda (Lundbeck), and Transcept Pharmaceuticals; has equity holdings in MedAvante; and has received royalty income from American Psychiatric Foundation, Guilford Publications, Herald House, Oxford University Press, and W.W. Norton. Dr. Thase’s spouse is employed by Embryon (formerly Advogent). Dr. Ketter has received consulting fees, advisory board fees, research support, royalties, or speakers honoraria from American Psychiatric Publishing, AstraZeneca, Astellas Pharmaceuticals, Bristol-Myers Squibb, Cephalon, Eli Lilly, Forest Pharmaceuticals, GlaxoSmithKline, Janssen Pharmaceutica, Merck, the NIMH Agency for Healthcare Research and Quality, Noven Pharmaceuticals, Pfizer, Sunovion, and XenoPort. Dr. Ketter’s spouse is an employee with and holds stock in Johnson & Johnson. Dr. Ostacher has served as a consultant to Sunovion. Dr. Leon has served on independent data and safety monitoring boards for AstraZeneca, Pfizer, and Sunovion; has received consulting fees from the Food and Drug Administration, MedAvante, NIMH, and Roche; and held equity in MedAvante. Dr. Reilly-Harrington has received royalties from the American Psychological Association and Oxford University Press, was a shareholder in Concordant Rater Systems, and has received consulting fees from Bracket Global. Dr. Iosifescu has received consulting or advisory board fees from Aspect Medical, Forest Pharmaceuticals, Ortho-McNeil, and Reed Medical (sponsor of the Massachusetts General Hospital Psychiatry Academy). Dr. Pencina consults for Pamlab and RCT Logic. Ms. Severe is a former employee of NIMH. Dr. Calabrese has received consulting fees, advisory board fees, research support, or speakers honoraria from Abbott, AstraZeneca, Bristol-Myers Squibb, Cephalon, Cleveland Foundation, Dainippon Sumitomo, Eli Lilly, EPI-Q, Forest Pharmaceuticals, France Foundation, GlaxoSmithKline, Health Resources Services Administration, Janssen, Johnson & Johnson, Lundbeck, Merck, NARSAD, Neurosearch, NIMH, Ortho-McNeil, Otsuka, Pfizer, Repligen, Schering-Plough, Servier, Solvay, Stanley Medical Research Institute, Supernus, Synosia, Takeda, the US Department of Defense, and Wyeth, and has provided CME lectures supported by AstraZeneca, Bristol-Myers Squibb, France Foundation, GlaxoSmithKline, Janssen, Johnson & Johnson, Merck, Pfizer, Sanofi-Aventis, Schering-Plough, Solvay, and Wyeth.Funded by NIMH contract NO1MH80001.

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