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Published Online: 21 April 2020

20-Year Trends in the Pharmacologic Treatment of Bipolar Disorder by Psychiatrists in Outpatient Care Settings

Abstract

Objective:

Pharmacological options for treating bipolar disorder have increased over the past 20 years, with several second-generation antipsychotics receiving regulatory approval in the 1990s. The authors describe trends in use of pharmacological agents in the outpatient management of bipolar disorder.

Methods:

Using nationally representative data from the 1997–2016 National Ambulatory Medical Care Surveys, the authors examined trends in the use of mood stabilizers, first- and second-generation antipsychotics, and antidepressants among psychiatrist visits for which bipolar disorder was listed among the primary diagnoses. A logistic regression model was used to identify statistically significant trends, with covariates including age, gender, race/ethnicity, and primary insurance.

Results:

Antipsychotics were increasingly more commonly prescribed, increasing from 12.4% of outpatient visits for bipolar disorder in the 1997–2000 period to 51.4% in the 2013–2016 period (adjusted odds ratio=5.05, 95% CI=3.65–7.01). Use of mood stabilizers decreased from 62.3% of visits for bipolar disorder in the 1997–2000 period to 26.4% in the 2013–2016 period (adjusted odds ratio=0.18, 95% CI=0.13–0.27). Prescription of antidepressants occurred in 47.0% of visits for bipolar disorder in the 1997–2000 period and 57.5% in the 2013–2016 period. Prescription of an antidepressant without a mood stabilizer increased substantially, from 17.9% in the 1997–2000 period to 40.9% in the 2013–2016 period (adjusted odds ratio=2.88, 95% CI=2.06–4.03).

Conclusions:

Substantial changes have occurred in the treatment of bipolar disorder over the past 20 years, with second-generation antipsychotics in large measure supplanting traditional mood stabilizers. Antidepressant prescriptions persisted despite a lack of evidence for their efficacy in bipolar disorder and concerns about increasing the risk of mania. Research is needed to compare the real-world effectiveness and tolerability of newer antipsychotics with those of traditional mood stabilizers.

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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: 706 - 715
PubMed: 32312111

History

Received: 29 September 2019
Revision received: 4 December 2019
Revision received: 24 January 2020
Accepted: 3 February 2020
Published online: 21 April 2020
Published in print: August 01, 2020

Keywords

  1. Bipolar Disorder
  2. Lithium
  3. Antipsychotics
  4. Outpatient

Authors

Details

Taeho Greg Rhee, Ph.D., M.S.W. [email protected]
Department of Public Health Sciences, School of Medicine, University of Connecticut, Farmington (Rhee); Department of Psychiatry, School of Medicine, Yale University, New Haven, Conn. (Rhee, Wilkinson); Department of Psychiatry, College of Physicians and Surgeons, Columbia University, New York (Olfson); and Center for Bipolar Treatment Innovation, Massachusetts General Hospital, and Department of Psychiatry, Harvard Medical School, Harvard University, Boston (Nierenberg).
Mark Olfson, M.D., M.P.H.
Department of Public Health Sciences, School of Medicine, University of Connecticut, Farmington (Rhee); Department of Psychiatry, School of Medicine, Yale University, New Haven, Conn. (Rhee, Wilkinson); Department of Psychiatry, College of Physicians and Surgeons, Columbia University, New York (Olfson); and Center for Bipolar Treatment Innovation, Massachusetts General Hospital, and Department of Psychiatry, Harvard Medical School, Harvard University, Boston (Nierenberg).
Andrew A. Nierenberg, M.D.
Department of Public Health Sciences, School of Medicine, University of Connecticut, Farmington (Rhee); Department of Psychiatry, School of Medicine, Yale University, New Haven, Conn. (Rhee, Wilkinson); Department of Psychiatry, College of Physicians and Surgeons, Columbia University, New York (Olfson); and Center for Bipolar Treatment Innovation, Massachusetts General Hospital, and Department of Psychiatry, Harvard Medical School, Harvard University, Boston (Nierenberg).
Samuel T. Wilkinson, M.D.
Department of Public Health Sciences, School of Medicine, University of Connecticut, Farmington (Rhee); Department of Psychiatry, School of Medicine, Yale University, New Haven, Conn. (Rhee, Wilkinson); Department of Psychiatry, College of Physicians and Surgeons, Columbia University, New York (Olfson); and Center for Bipolar Treatment Innovation, Massachusetts General Hospital, and Department of Psychiatry, Harvard Medical School, Harvard University, Boston (Nierenberg).

Notes

Send correspondence to Dr. Rhee ([email protected]).

Competing Interests

Dr. Nierenberg has served as a consultant for Abbott Laboratories, Alkermes, American Psychiatric Association, Appliance Computing (MindSite), Basliea, Brain Cells, Brandeis University, Bristol-Myers Squibb, Celexio, Clintara, Corcept, Dainippon Sumitomo (now Sunovion Pharmaceuticals), Dey Pharmaceuticals, Eli Lilly, EpiQ, Forest, Genaissance, Genentech, GlaxoSmithKline, Healthcare Global Village, Hoffman LaRoche, Infomedic, Intra-Cellular Therapies, Janssen Pharmaceutica, Jazz Pharmaceuticals, L.P./Mylan, Lundbeck, MedAvante, Merck, MSI Methylation Sciences, Naurex, Neurocrine, Neuronetics, NeuroRx, Novartis, Otsuka, Pamlab, Parexel, Pfizer, PGx Health, Ridge Diagnostics, Sage Pharmaceuticals, Schering-Plough, Shire, Somerset, Sunovion Pharmaceuticals, Supernus, Takeda Pharmaceuticals, Targacept, and Teva, and he has also served as a consultant through the MGH Clinical Trials Network and Institute (CTNI) for Assurex, AstraZeneca, BrainCells, Dainippon Sumitomo/Sepracor, Johnson & Johnson, LaboPharm, Merck, MSI Methylation Sciences, NeuroRx Pharma, Novartis, Pfizer, PGx Health, Physician’s Postgraduate Press, Schering-Plough, Shire, Takeda/Lundbeck, and Targacept; he has received honoraria from American Drug Utilization Review, American Professional Society of ADHD and Related Disorders, American Society of Clinical Psychopharmacology, Baystate Medical Center, Belvoir Publishing, Brandeis University, Bristol-Myers Squibb, CME Institute, Columbia University, Congress of the Hellenic Society for Basic and Clinical Pharmacology, CRICO, Dartmouth Medical School, Guilford Publications, Harold Grinspoon Charitable Foundation, Health New England, Hillside Hospital, IMEDEX, Institute of Medicine, International Society for Bipolar Disorders, International Society for CNS Clinical Trials and Methodology, Israel Society for Biological Psychiatry, Johns Hopkins University, MBL Publishing, Medscape, MGH Psychiatry Academy, MJ Consulting, NAMI, National Association of Continuing Education, National Network of Depression Centers, New Clinical Drug Evaluation Unit, New York State, Nova Southeastern University, Physicians Postgraduate Press, Psychiatric Annals, Rush Medical College, SciMed, Slack Publishing, SUNY Buffalo, University of Miami, University of Michigan, University of Pisa, University of Texas Southwestern Dallas, University of Wisconsin at Madison, UpToDate, Wiley Publications, Wolters Kluwer Publishing, World Congress on Brain Behavior and Emotion, and Yale University School of Medicine; he has served on advisory boards of Appliance Computing, Brain Cells, Eli Lilly, Genentech, InfoMedic, Johnson & Johnson, Takeda/Lundbeck Pharmaceuticals, and Targacept; he owns stock options in Appliance Computing (MindSite), Brain Cells, and MedAvante; and he has copyrights on the Clinical Positive Affect Scale and the MGH Structured Clinical Interview for the Montgomery-Åsberg Depression Rating Scale exclusively licensed to the MGH Clinical Trials Network and Institute. Dr. Wilkinson has received contract funding from Janssen and Sage Therapeutics for the conduct of clinical trials administered through Yale University, and he anticipates receiving contract funding from LivaNova for conducting clinical trials; he has received consulting fees from Biohaven Pharmaceuticals, Janssen, and Oui Therapeutics. The other authors report no financial relationships with commercial interests.

Funding Information

National Institute on Drug Abusehttp://dx.doi.org/10.13039/100000026: R01DA019606, R01DA039137
Agency for Healthcare Research and Qualityhttp://dx.doi.org/10.13039/100000133: K12HS023000
National Institute of Mental Healthhttp://dx.doi.org/10.13039/100000025: R01MH107452
National Institute on Aginghttp://dx.doi.org/10.13039/100000049: T32AG019134
Supported by NIH grant T32AG019134 (Dr. Rhee), NIH grants R01MH107452, R01DA039137, and R01DA019606 (Dr. Olfson), the Thomas P. Hackett, M.D., Endowed Chair in Psychiatry at Massachusetts General Hospital (Dr. Nierenberg), the Dauten Family Center for Bipolar Treatment Innovation (Dr. Nierenberg), Agency for Healthcare Research and Quality grant K12HS023000 (Dr. Wilkinson), the Brain and Behavior Research Foundation (Dr. Wilkinson), the Robert E. Leet and Clara Guthrie Patterson Trust (Dr. Wilkinson), and the American Foundation for Suicide Prevention (Dr. Wilkinson).

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