Advances in the psychopharmacotherapy of bipolar disorder type I

ABSTRACT

INTRODUCTION

Research into the pharmacologic management of bipolar type I illness continues to progress.

AREAS COVERED

Randomized clinical trials performed with type I bipolar disorder in the years 2015 to August 2020 are reviewed. There are new indications for the use of cariprazine, for bipolar mania and depression, and a long-acting injectable formulation of aripiprazole has also been approved for relapse prevention in bipolar illness. Most of the randomized clinical trials are effectiveness studies.

EXPERT OPINION

Over the 20 years from 1997 through 2016, the use of lithium and other mood stabilizers has declined by 50%, while the use of both second-generation antipsychotics (SGAs) and antidepressants has increased considerably. Over the same time period (1990–2017), disability-adjusted life years (DALYs) increased by 54.4%, from 6.02 million in 1990 to 9.29 million in 2017 which is greater than the 47.74% increase in incidence of the disease, suggesting that the changes in prescribing patterns have not been helpful for our patients. Furthermore, recent effectiveness studies continue to confirm the superiority of lithium and other mood stabilizers in the management of bipolar illness for both psychiatric and medical outcomes, reaffirming their role as foundational treatments in the management of type I bipolar disorder. Clinicians need to reassess their prescribing habits.

KEYWORDS:

• Antidepressants
• bipolar disorder
• depression
• mania
• mood stabilizers
• psychopharmacotherapy
• treatment

Article highlights

1. The number of medications approved for AUD is small and they generally have limited efficacy (naltrexone, acamprosate and disulfiram).

2. These changes parallel the introduction of antipsychotics as a first-line treatment option in the treatment of bipolar mania, bipolar depression, and bipolar maintenance treatments. • However, these very same changes are associated with an increase of disability-adjusted life years (DALYs) of 54.4% among subjects with bipolar disorder.

3. Over the last 5 years, effectiveness research has reinforced the superior utility of mood stabilizers over antipsychotics, and the lack of utility and increased risk of antidepressants in the treatment bipolar I disorder.

4. Use of antipsychotics or antidepressants as initial interventions in bipolar I disorder do not improve outcome and increase unwanted and unintended adverse consequences.

5. Prescribers caring for patients with type I bipolar disorder should reconsider their approach to managing their patients, particularly if they notice their use of mood stabilizers decreasing, or their use of antipsychotics and/or antidepressants increasing.

Declaration of interest

R. El-Mallakh is one of the speakers of the bureau of the following companies: Alkermes, Eisai, Indivior, Intra-Cellular Therapeutics, Janssen Pharmaceuticals, Lundbeck, Noven, Otsuka, Sunovion, and Teva. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

One referee declares having served on the Medscape Steering Committee on Clinical Advances in Postpartum Depression. They have also received honoraria from Medscape and Miller Medical Communications. Furthermore, they have served on Advisory Boards for Sage Therapeutics, and is a Council Member of the Gerson Lehrman Group. They have also served as a consultant Ovia Health, Sage Therapeutics or their agents, and has received speaking honoraria from Sage Therapeutics. Peer reviewers on this manuscript have no other relevant financial relationships or otherwise to disclose.

Additional information

Funding

This manuscript was not funded.