Heavy Psychotropic Med Burden Common in Bipolar Patients

Fran Lowry

February 06, 2014

Individuals with bipolar disorder carry a heavy medication burden, with many taking up to 6 different drugs, including medicines for other psychiatric conditions, new research shows.

The study shows that more than one third of bipolar patients admitted to a psychiatric hospital were receiving complex polypharmacy with 4 or more psychotropic drugs from community providers.

In addition, women were significantly more likely than men to be the recipients of polypharmacy.

"This high medication burden is something to be concerned about, because there are numerous side effects, and there might be drug-drug interactions," lead author Lauren Weinstock, PhD, from the Alpert Medical School of Brown University, Providence, Rhode Island, told Medscape Medical News.

"The more medications people take, the harder it is to adhere to the correct way they were prescribed, and also it is obviously very costly to patients. Whether it is rational or irrational prescribing, it is still a burden, and it can be problematic for these patients," Dr. Weinstock said.

The study was published online February 1 in Psychiatry Research.

Need for Balance

After noticing that there seemed to be a high rate of complex polypharmacy among the patients with bipolar disorder being admitted to Butler Hospital, in Providence, the investigators decided to quantify their clinical observations.

They conducted a chart review of 230 patients aged 18 years and older diagnosed with bipolar I disorder who were admitted during 2010.

The review showed that when the patients presented to the hospital, they were taking an average of 3.3 psychotropic drugs, and an average of 5.9 drugs overall.

More specifically, 81% were taking 1 or more psychotropic drugs, 72% were taking 2 or more, 55% were taking 3 or more, and 36% (n = 82) were taking 4 or more psychotropic drugs, thus meeting the criteria for complex polypharmacy.

The review also showed that 19% of patients were not taking any psychotropic drugs at all.

Women made up the majority of bipolar disorder patients receiving complex polypharmacy, accounting for 68%, compared with 32% accounted for by men (P = .025).

Women were also more likely to be depressed, have a comorbid anxiety disorder, and have a history of suicide attempt. They were also significantly more likely than men to be prescribed antidepressants, benzodiazepines, and stimulants, even after controlling for mood episode polarity.

Dr. Lauren Weinstock

"Women's odds of having complex polypharmacy were 1.78 times greater than men's. Our study did not go into the reasons why, but the finding is important, because treatments with benzodiazepines and stimulant medications are controversial in the management of bipolar disorder," Dr. Weinstock said.

A psychologist, Dr. Weinstock says the study raises the question of the utility of psychotherapy and other nonpharmacologic treatments, rather than simply augmenting a patient's treatment with numerous medications.

"There’s a fine line between help and harm. Obviously, doctors are trying to do the best they can to treat people, and if that means adding additional medications, that is an important consideration. But it also has to be balanced against what we described as the medication burden of taking so many medications all at once," she said.

"When it's helpful, perhaps the benefits outweigh the risks, but when people aren't deriving symptom improvement and yet they are still on numerous medications concurrently, it does raise some questions about what the next step is for that patient and what we can do in the field to streamline treatment for them."

Polypharmacy Often Necessary

Complex polypharmacy for bipolar disorder is not necessarily a bad thing, Michael E. Thase, MD, professor of psychiatry, Perelman School of Medicine at the University of Pennsylvania, in Philadelphia, told Medscape Medical News.

Dr. Michael Thase

"The issue is that relatively few people with bipolar disorder respond to 1 particular medicine, like lithium, for example, and there is some evidence that the different kinds of medicine that are used have complementary or additive effects," said Dr. Thase, who was not part of the study.

"Bipolar disorder is a condition in which there are many different kinds of medicine that have been approved. If people aren't responding to one, they get a second added, and then sometimes a third, and sometimes a fourth, so the issues that pertain here are cases where ineffective medicines are not being discontinued and safely being properly monitored in people who are taking these complex regimens," he said.

"Polypharmacy is not necessarily a bad thing. What is a necessary consideration is each time you have made the regimen more complex, have you properly evaluated whether the medicine that is not helping enough should be stopped or continued?

"Are you monitoring the effects on weight, metabolism, concentration and cognition, alertness, and all of those things? That is part of the obligation you have as a clinician. The more medicines you use, you have an obligation to make sure you're not using more complex regimens than you need to," said Dr. Thase.

"With so many patients getting 3, 4, 5 different medications, are we doing a good enough job and making sure that they are taken off the drugs that aren't useful and being put on other medicines and monitoring them carefully? That is the issue."

Dr. Weinstock reports no relevant financial relationships. Dr. Thase reports that he consults with the manufacturers of every medicine used to treat psychiatric patients.

Psychiatry Res. Published online February 1, 2014. Abstract


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