Recurrence of Mania or Depression Among Adult Bipolar Patients Who Continued Using Lithium: A Single-group Summary Meta-analysis of Randomized Trials

Lorazepam use during clinical trials of adults with bipolar mania episodes

Background

Lorazepam has commonly been prescribed to reduce agitation during bipolar 1 mania trials. Its use has varied considerably by trial methodology and in clinical practice.

Methods

The extent and amount of lorazepam treatment was recorded and analyzed from available brief, controlled trials of acute bipolar mania and in clinical reports in adults.

Results

In 3-week, placebo-controlled clinical trials (n = 19), most manic subjects (79%) were treated with lorazepam to reduce agitation. This treatment was most prominent during the antimanic drug wash-out phase that preceded placebo-controlled trials. Doses of lorazepam administered during the first 7-10 days of the pre-trial and the early trial phases averaged 2.2 mg/day. These doses were one-third the lorazepam/clonazepam doses administered during placebo-controlled, non-washout trials. Far higher benzodiazepine doses for manic agitation were noted in emergency department reports. Intake enrollment was strikingly restricted only in placebo-controlled trials that used pretrial drug wash-out.

Conclusions

Medication treatment conclusions from placebo-controlled, drug washout trials are not representative of clinical treatment for acute bipolar mania.

Differences in the prophylactic effect of serum lithium levels on depression and mania in bipolar disorder: A dose-response meta-analysis

The optimal serum lithium levels for preventing the recurrence of mood episodes in bipolar disorder are controversial, especially when polarity is considered. The present study aimed to comprehensively examine the dose-response relationship between lithium concentration and risk of recurrence of mood episodes. We conducted a systematic search of major databases before January 2021 (PROSPERO: CRD42021235812). A one-stage, random-effects, restricted cubic splines model was used to estimate the dose-response relationship between lithium concentration and risk of recurrence of any or specific mood episodes (depression or mania). The effect size is shown as odds ratio (OR). Our meta-analysis included six randomised controlled trials with a total of 975 participants. The dose-response curve showed that increased serum concentrations were associated with a gradual decrease in the risk of any mood episodes (OR 0.50 at 0.60 mmol/l, OR 0.15 at 1.20 mmol/l). The risk of depression decreased slightly with a concentration of 0.60 mmol/l (OR 0.83) but dropped rapidly as the concentration increased to 1.20 mmol/l (OR 0.39). By contrast, the risk for mania initially decreased steadily (OR 0.44), but decreased only marginally (OR 0.30) as the concentration increased. To reduce the recurrence risk to 56%, prevention of depression required a higher concentration than that required for mania (1.13 mmol/l vs. 0.60 mmol/l). Our results suggest a negative dose-response relationship between serum lithium levels and risk of recurrence. In particular, the different preventive effects of serum concentration on depression and mania will be an important clinical reference.

Advances in the psychopharmacotherapy of bipolar disorder type I

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.