Real World Effectiveness of Meds for Bipolar disorder

Real World Effectiveness of Meds for Bipolar disorder

by Sareen -

I was looking forward to discussing this article (Lahteenvio et. al., 2018) because it was an article that my preceptor had given to me to read since it was “hot off the press” as it was recently published. During journal club we discussed that this was an observational study. Initially I thought that this meant the study was not as strong, since it was not a gold standard randomized control study. I appreciated our discussion and reminder that an observational study is not necessarily less rigorous/strong, but it is different. In an observational study we are understanding correlation, not necessarily causation. An advantage to this type of research is the potential increased generalizability because it is more representative of patients in their natural environment.

The main measurement this study looked at was re-hospitalization rates. Some big take home conclusions from the study were that Lithium was associated with reduced risk of psychiatric and all-cause hospitalizations. Another take home was that quetiapine did not significantly reduced re-hospitalization rates, and that Long-acting injectable antipsychotics were also associated with a lower risk of re-hospitalization compared to oral equivalents.

The conclusion with Lithium was not surprising, as it is the gold standard of treatment for patients with Bipolar disorder, known for its effectiveness at treating mania and suicidality, which are the two main reasons for hospitalization. Thus, it makes sense that patients treated with Lithium will have reduced rates of hospitalization. Personally, this is just another reminder to use Lithium as my go-to medication for bipolar disorder (with consideration of co-morbid conditions, lab compliance, etc. of course). We discussed in class that Lithium is a drug that requires more work for the prescriber, and thus often patients are placed on atypical antipsychotics as monotherapy.

In some ways these conclusions hit home, as I recently cared for a patient who was newly diagnosed with Bipolar disorder but was only placed on a low dose of quetiapine 200mg QHS (she adamantly refused to increase her dose… it took me 3 appointments to increase her to 250mg!). The meds were barely holding her, and she eventually became manic and quite psychotic, ingested Tylenol as a suicide attempt, hospitalized, and now she is on Lithium and risperidone, being cared for by my psychiatrist colleague. This was a real-life example of the conclusions to this article, which I also recognize is a bias that I have when reading this article.

Interested to hear others’ thoughts on this article.


Reference: 

Lahteenvuo, M., Tanskanen, A., Taipale, H., Hoti, F., Vattulainen, P., Vieta, E., and Tiihonen, J. (2018). Real-World effectiveness of pharmacologic treatments for the prevention of rehospitalization in a Finnish nationwide cohort of patients with bipolar disorder. JAMA Psychiatry, February 28, 2018. doi: 10.1001/jamapsychiatry.2017.4711.

 

 


Re: Real World Effectiveness of Meds for Bipolar disorder

by Nana Efua Adabie -

Sareen,

Thank you for your detailed post and a brief summary of the article. I share the same ideas and opinions as yourself. There is no doubt that Lithium is a "gold standard" for bipolar disorder. Just like you said, it is well used in clinical practice and this observational study just supports the strengths of lithium. The observational design of this study may not be considered as strong as a Randomized Control Trial, however, since lithium, for many years have proved to be very efficacious, it dims down just a bit the critical critique of how this study could be better.

Lithium reduces risk for re-hospitalizations as found in this study, but the question you posed, and I also pose is why then are providers still prescribing antipsychotics for mood disorders or bipolar disorders without trying lithium first. The evidence is there, and it shows how efficacious lithium is. I agree with you, that yes, lithium comes with a lot more work and monitoring on the provider's side, which can prevent it's prescription. This raises up the question of are we doing this for our patients or for our own comfort? The amount of work should not matter to us as providers as long as we are providing the best and most effective care and medications to our patients.  Of course, every patient is different and treatment should be tailored to them, however, it can be an ethical dilemma when providers start to consider their own comfort over the best care for patients.


Looking forward to reading other's post and opinions about this topic.


Lahteenvuo, M., Tanskanen, A., Taipale, H., Hoti, F., Vattulainen, P., Vieta, E., and Tiihonen, J. (2018). Real-World effectiveness of pharmacologic treatments for the prevention of rehospitalization in a Finnish nationwide cohort of patients with bipolar disorder. JAMA Psychiatry, February 28, 2018. doi: 10.1001/jamapsychiatry.2017.4711.

Re: Real World Effectiveness of Meds for Bipolar disorder

by Lauren -

Sareen, 
As you mention, we need to consider a little more closely as to why patients would not be prescribed lithium. While we must concede that there could be provider bias against additional monitoring and the relatively narrow therapeutic window, there are also compelling reasons not to prescribe lithium, including other medical illness and patient difficulty in maintaining an oral regimen. Lithium is generally contraindicated in patients with renal failure, cardiovascular insufficiency, untreated thryoid disoder and patients with dehydration and/or sodium depletion (Janicak, 2018). While lithium considerably lowers the suicide risk (Tondo & Baldessarini, 2016), there are reasons not to prescribe it in patients who would otherwise be eligible for this medicine. 

As an example, I have a client who I'm following who is acutely manic, homeless (living in a van), does not tolerate regular lab work, and questions her own ability to take medicine on a regular basis. While lithium may have the best outcomes when it comes to hospitalizations (Lahteevo et al. 2018), for her in particular having coverage with a long-acting injectable was what we decided upon from a shared decision-making perspective. This is to say that while lithium may be best, there are other reasons beyond provider reluctance that may be contributing to prescriptive practices. 

References:
Janicak, P. (2018). Bipolar disorder in adults and lithium: Pharmacology, administration, and side effects. In P. Keck (Ed.). Retrieved from: https://www-uptodate-com.ucsf.idm.oclc.org/contents/bipolar-disorder-in-adults-and-lithium-pharmacology-administration-and-side-effects

Lahteenvuo, M., Tanskanen, A., Taipale, H., Hoti, F., Vattulainen, P., Vieta, E., and Tiihonen, J. (2018). Real-World effectiveness of pharmacologic treatments for the prevention of rehospitalization in a Finnish nationwide cohort of patients with bipolar disorder. JAMA Psychiatry, February 28, 2018. doi: 10.1001/jamapsychiatry.2017.4711.

Tondo, L., & Baldessarini, R. (2016). Suicidal behavior in mood disorders: Response to phamacological treatment. Current Psychiatry Reports, 18, 88. 

 


Re: Real World Effectiveness of Meds for Bipolar disorder

by Alexa -

Hi all,

To piggyback on Lauren's comments on contraindications for lithium, I want to add that lithium is also a double-edged sword for patients who are at risk for suicide. It is indeed a valuable agent to protect against suicidality (and mania and depression), but it also can easily lead to suicide with a toxicity overdose. As my classmates mentioned above, the decision on whether or not to initiate lithium therapy should always be an individualized one - taking into consideration factors including comorbidities, age, substance use (which can influence toxicity by dehydration), history of past trials on lithium, renal function, thyroid function, suicide risk, and adherence to lab monitoring. 

With respect to comorbidities to consider, Alexander et al. (2008) explain that hypertension, mitral valve insufficiency, hyperparathyroidism, hyperuricemia, and diabetes each have the potential to potentiate kidney damage with long term use. Finally, I think it's also important to consider the patient's quality of life on the medication. With up to to 50% of patients who take lithium undergoing substantial weight gain, coupled with a rather unpleasant side effect profile, the decision to take lithium ought to be taken with caution and a shared decision between the patient and provider. Once graduated and in practice, I plan to (continue to) use lithium frequently in patients with bipolar disorder, and with a careful analysis of pros vs cons for the individual patient. 

References:

Alexander, M. P., Farag, Y. M. K., Mittal, B. V., Rennke, H. G., & Singh, A. K. (2008). Lithium toxicity: a double-edged sword. Kidney international, 73(2), 233-237.

Re: Real World Effectiveness of Meds for Bipolar disorder

by Evelyn Cunningham -

What a great discussion thread!  I'm sorry that I was not able to make it to the journal club for this week.  Sareen - thank you for a solid summary of the article, as well as looping those of us who were not present into the meat of the discussion.  I ran into a similar situation when I was examining articles for my comp with regards to how to evaluate the evidence.  I like your comment that Observational studies are merely different, and should be examined as such.  The fact that we have a breakdown of levels of evidence is not just to be able to say one study is objectively better than another, but rather, it is a helpful tool in understanding the results.  It puts it into context.  While we might not be able to draw the conclusion that X intervention leads directly to outcome Y, observational studies can show us correlation.  This is helpful in maintaining a natural environment, as well as looking at multiple variables that can go into a single effect.

As far as what goes into prescribing Lithium, I agree with all of the above comments in that it is a multifaceted issue.  Despite evidence of efficacy, there are multiple other considerations that go into this prescription, including the need for monitoring, risk of toxicity, and considerations regarding kidney function.  I think that this is more than simplicity on the part of the provider, but rather a constellation of the site's norms, patient situation, as well as past experience.  Due to it being one of the original medications used to treat BPD, it also has extensive research regarding long term outcomes, which may contribute to higher caution.  This is something that I recently discussed in a med education group with patients - that sometimes new meds can seem more beneficial, however this may actually reflect a lack of evidence rather than consensus that there are no long term negative effects.  Something to think about when talking with patients!


Lahteenvuo, M., Tanskanen, A., Taipale, H., Hoti, F., Vattulainen, P., Vieta, E., and Tiihonen, J. (2018). Real-World effectiveness of pharmacologic treatments for the prevention of rehospitalization in a Finnish nationwide cohort of patients with bipolar disorder. JAMA Psychiatry, February 28, 2018. doi: 10.1001/jamapsychiatry.2017.4711.

Re: Real World Effectiveness of Meds for Bipolar disorder

by Matthew Settle -


Thanks all for a stimulating discussion. I REALLY found this article interesting, and agree with most of what has been said in this thread thus far. I want to just insert a few thoughts that came up for me as I was reading...

As stated, I found this to be a very interesting study. Several things stuck out to me. First, I have to ask the question as to whether there may be something about an individual who is at a point in their life in which they are taking LAIs that might predispose them to fewer rehospitalizations separate from the LAIs themselves.

Another piece of information, which is kind of an aside, that I found interesting was the fact that gabapentin was shown to be so effective. In my limited experience, I had not even known that gabapentin was something that was used as a monotherapy for bipolar disorder. This is something that I am going to need to research further.

Finally, that mood stabilizers were associated with an increased risk of medical hospitalization for cardiovascular issues, but not lithium, was very interesting. This is something to keep in mind when considering Depakote or carbamazepine versus lithium in the future.


Re: Real World Effectiveness of Meds for Bipolar disorder

by Michelle -

Such an interesting discussion everyone!  As I called in to the journal club from afar and after reading these posts now, it seems like the main conclusions have already been identified, that lithium is the best at preventing hospitalizations and that long acting injectables (LAI) are also effective at lowering the rate of hospitalizations. I thought I would draw the discussion to LAIs since Lithium has been discussed thoroughly in this thread already. I found it intriguing that LAI were able to lower the risk of rehospitalization by 30% as compared to the same medication taken orally. This seems like quite a big difference and something that should be discussed with clients and/or families when explaining the medication options. Per UpToDate, the rates of medication adherence between LAI and their oral counterparts is pretty much the same, so I wonder what we are missing. Clients are taking or not taking their medications (LAIs and PO) at the same rates, but clients taking LAIs are decompensating less. I would love to see more data on this topic. I would also love to hear from all of you about how you discuss antipsychotics with your clients when talking about oral medications and LAI. Do you offer both options (assuming they will have a PO trial before the LAI) without discussing the pros and cons of each route? A lot of people seem to be needle resistant, but would maybe feel differently if they heard about the potential lower risk of rehospitalization. Does anyway wait to offer a LAI until you find that a client has difficulty with remembering to take medications daily?

I think this is a great discussion, especially for any of us who plan to work with transitional aged youth or folks who are experiencing their first bipolar or psychotic event. Since we know that reducing the amount of manic episodes or psychotic episodes is critical for prognosis, I wonder if prescribing LAIs sooner in treatment will become more common. What do you all think?

https://www.uptodate.com/contents/bipolar-disorder-in-adults-managing-poor-adherence-to-maintenance-pharmacotherapy?sectionName=Long-acting%20injectable%20antipsychotics&topicRef=680&anchor=H519214169&source=see_link#H519214169

Re: Real World Effectiveness of Meds for Bipolar disorder

by Alexa -

Michelle,

Great post! Your comments on LAI injectables got me thinking. I ended up bringing this study to the psychiatrist I work with in my clinical setting; I was curious to hear his thoughts on because I haven't yet seen him prescribe a LAI injectable during my time with him. He mentioned that some of his reluctance with prescribing LAIs is that he would have to administer the LAI to the patient himself in the outpatient setting. I offered to do them, but he wasn't sure if we are even allowed to administer LAIs in our outpatient psychiatric setting. This struck me as a little odd, so I'm going to ask management more about this. Additionally, he noted that the dosing in the oral medications don't exactly equate to the LAIs, and he simply isn't as familiar with using them so he doesn't. I would be curious to hear others' thoughts and experiences on how dosing/tolerability differs from the oral version to the LAI version? 


Re: Real World Effectiveness of Meds for Bipolar disorder

by Lauren -

Alexa - that's interesting that there are restrictions at your clinical setting around administering LAIs. I wonder about the rationale behind that policy, or if it's the provider who does not want to schedule that frequent of a visit. Several of the clients who I follow are on LAIs; I find that for certain people it helps provide structure and consistency that I see them every two weeks for their Haldol Decanoate. It helps keep them connected to services, and allows for me to have more frequent check-ins. My experience with LAIs mirror the literature that indicates that people on LAIs are less likely to be hospitalized as compared to those on oral medicine (Maestri, T.J., Mican, L.M., Rozea, H., & Barner, J.C., 2018), however I wonder if the clients I have who are on LAIs are also my more clinically stable clients, which is reflective of their ability to stay consistent with scheduling their injection. That said, my experience of more stable clients on LAIs differs from a meta-analysis indicating that clients on LAIs may actually be more severely ill (Kishimoto et al, 2017). 

Michelle - I'm a bit surprised to read that UpToDate indicates that the adherence to oral and LAI medications are roughly the same. I too would be interested in reading more on this - and while anecdote is not evidence, in my own experience I find clients to be far more adherent on LAIs, for example a client who is on both a LAI (Haldol Decanoate) and Fluoxetine. He schedules his month around his injections, however the PO adherence is pretty hit or miss. As for broaching the subject of oral versus LAI - that conversation happens once someone has trialed though the PO counterpart and remained adherent and with few side effects. As for the ease-factor of not taking oral medication, I don't have anyone who is on exclusively a LAI, so that's tough to say. 

References
Kishimoto, T., Hagi, K., Nitta, M., Leucht, S., Olfson, M., Kane, J.M., & Correll, C. (2017). Effectiveness of long-acting injectable vs oral antipsychotics in patients with schizophrenia: A meta-analysis of prospective and retrospective cohort studies. Schizophrenia Bulletin, 44(3), 603-629. 

Maestri, T.J., Mican, L.M., Rozea, H., & Barner, J.C. (2018). Do long-acting injectable antipsychotics prevent or delay hospital readmission? Psychopharmacological Bulletin, 48(13), 8-15. 

Re: Real World Effectiveness of Meds for Bipolar disorder

by Abigail -

I was also surprised to hear that oral and long acting IM antipsychotic adherence are essentially the same. I first heard this while listening to a podcast last year, but I can't remember which one! I continue to wonder, though, how are we truly measuring oral adherence? The PRE2DUP method used in this study seems to be quite reliable, but I can't imagine the same is true for self-report. Of course, this is a question worthy of an entire comp exam, so I won't attempt to research that for this thread, but it is something that I would like to learn more about. 

Lauren, I have similar thoughts about the therapeutic effect of more frequent check-ins with patients on LAIs. Most of the patients I followed at Fred Finch were on LAIs and, for the most part, were adherent. Some were exclusively on LAIs while others were on several medications. In my brief experience at Fred Finch, I definitely saw better adherence to LAIs than self-reported adherence to oral meds, including antipsychotics. 

References:

Kishimoto, T., Hagi, K., Nitta, M., Leucht, S., Olfson, M., Kane, J.M., & Correll, C. (2017). Effectiveness of long-acting injectable vs oral antipsychotics in patients with schizophrenia: A meta-analysis of prospective and retrospective cohort studies. Schizophrenia Bulletin, 44(3), 603-629. 

Re: Real World Effectiveness of Meds for Bipolar disorder

by Julia -

Michelle, 

I'm so glad that you addressed the question of medication adherence in long acting injectables vs. oral equivalents. I found myself wondering about this too and I am surprised to hear that the adherence rates are comparable. I wonder, then, what accounts for the difference in re-hospitalization rates seen in this study. 

I can't offer much from my own clinical experience, I am at the same site as Alexa and have not seen a single patient on a long acting injectable (though we see many patients with bipolar disorder and frequently prescribe both antipsychotics and lithium). This also brings up the question of how relevant these results are to less acute populations. One thing to consider with this study, is that all of the patients in the study were initially hospitalized, and the outcome measure was re-hospitalization. It makes me wonder if the results would also hold true among individuals with bipolar disorder who have no history of hospitalization? 

I was able to find one RCT that compared long acting injectable risperidone vs. oral antipsychotic medication in the outpatient treatment of bipolar disorder, which found that the two had similar efficacy, safety and tolerability (Yatham, Fallu & Binder, 2007). I wonder if the difference in efficacy between the two different formulations becomes more pronounced in more acute cases? What do people think? 


Yatham, L. N., Fallu, A., & Binder, C. E. (2007). A 6‐month randomized open‐label comparison of continuation of oral atypical antipsychotic therapy or switch to long acting injectable risperidone in patients with bipolar disorder. Acta Psychiatrica Scandinavica, 116(s434), 50-56.


Re: Real World Effectiveness of Meds for Bipolar disorder

by Michelle -

Thanks for looking into this more, everyone! It has been a really interesting discussion around LAI use. Lauren, I appreciated your response with your own clinical experience. I, too, have a client on Haldol dec who I see every two weeks and it has been really valuable to be able to see him so often. He has has been taking oral medication and the LAI for several years now and hasn't been in the hospital for a decade. He is also terrified of having another manic episode so he is very attached to his medication regimen and very against making any changes. I foresee this being a challenge as he gets older and requires less medication and/or is more susceptible side effects. 

Since my original post was related to prescribing LAIs to children, I wanted to bring our attention the 2017 article that Chelsea posted on our class CLE page about LAI use in children and adolescents (Lytle, McVoy, & Sajatovic, 2017). The researchers found that LAI use in children may improve long-term adherence and prognosis, however, they recognize that there is a lack of data in this field and that more research is needed moving forward. I appreciate everyone thinking about this and talking about it since I haven't seen LAIs prescribed to adolescents in my child outpatient clinical and I think it could be a good option for several patients. 

Lytle, S., McVoy, M., & Sajatovic, M. (2017). Long acting injectable antipsychotics in children and adolescents. Journal of Child and Adolescent Psychopharmacology, 27(1), 2-9. 

Re: Real World Effectiveness of Meds for Bipolar disorder

by Sareen -

Matt, wanted to bring the topic of gabapentin back up since you mentioned it in your post. We actually discussed this during journal club because we also were surprised to see Gabapentin listed as a “favored use” drug. My understanding of the chart (please correct me if I am mistaken) is that Gabapentin was associated with lowest risk of psychiatric rehospitalization. But we also pointed out in our critique of the chart that it does not indicate if these medications were used by themselves or in conjunction with other meds. You are right in that gabapentin is not a commonly used (or shown to be effective) monotherapy for bipolar disorder. When I worked in inpatient, I saw Gabapentin prescribed a lot as adjunctive treatment (for anxiety, pain, substance use). During journal club we were theorizing that perhaps gabapentin is well tolerated and given for many people in psych hospitalizations, but not necessarily as monotherapy. In that way the chart felt misleading.

But in terms of research for the use of gabapentin in bipolar disorder, Berlin, Butler & Perloff (2015) conducted a review of gabapentin in psychiatric disorders and found that gabapentin is not effective as monotherapy for managing mania or depressive symptoms in bipolar disorder. Most studies found that it was not very effective as adjunctive therapy, although some studies found that when it was combined with lithium, it did help with manic symptoms. It was not found to be harmful, so it can possibly be considered in individual cases. Overall, though, not great evidence for use in bipolar disorder.

Knowing that Gabapentin is less likely efficacious for bipolar disorder, it seems like the gabapentin in this article is clinical data “noise” and not very relevant for thinking about preventing psych hospitalizations for patients with bipolar disorder.


References:

Berlin, R. K., Butler, P. M., & Perloff, M. D. (2015). Gabapentin therapy in psychiatric disorders: A systematic review. Primary Care Companion CNS Disorders, 17(5). doi: 10.4088/PCC.15r01821.


Re: Real World Effectiveness of Meds for Bipolar disorder

by Julia -

Sareen and Evelyn, 

I appreciate  the point that you both raise regarding the relative pros and cons of observational studies. I'd like to echo that this particular article really made me reflect on what types of studies are most useful for clinical practice and what my own biases are when reading about different study designs. It is interesting that we are always taught to consider RCTs to be the gold standard of research. I certainly tend to favor RCTs, while generally taking other types of studies less seriously. 

This journal club, though, really drove home the fact that observational studies can provide incredibly valuable information in ways that RCTs cannot. Because of strict inclusion/exclusion criteria, RCT's often fail to capture the true lived experiences of the patients we treat. An RCT can let us say with confidence that one medication is more effective than a placebo in treating patients who have a specific diagnosis without any co-morbid medical or psychiatric conditions. However, we rarely see such a "neat" presentation in practice. For that reason, observational studies such as this particular study offer a valuable way to see general trends experienced by patients we treat. 

That said, given the limitations of the observational study design, I will probably not attribute too much to the specific differences between particular medications (for example, outcomes between different oral antipsychotics in this study). Because there are so many variables that cannot be controlled, the results of this study must be taken cautiously. I do feel, though, that the results regarding entire classes of medications (for example, that lithium and LAIs are most efficacious) will inform my future practice. 


Re: Real World Effectiveness of Meds for Bipolar disorder

by Lauren -

Julia,
Good points about observational studies and RCTs. I had not considered that RCT’s may fail to capture the true lived experience of patients, and following a study protocol may not be reflective of the real word. In considering study design, there are some study outcomes that cannot be ethically manipulated or subject to randomization, for example withholding psychotropic medication, or providing people with a placebo to evaluate post-surgical pain relief. In considering the strengths of an RCT, as you mention it’s considered the gold standard of research for many obvious reasons, including that causation can be established within this study design. Within this strict study design, ideal practices and homogeneous patient populations can be evaluated, however the real-word efficacy may be better evaluated using an observational study design. Additionally, in contrast to RCTs, it is much easier to maintain equipoise in an observational study.

Ultimately, it’s important to evaluate research in context as opposed to in isolation. In considering how to evaluate an RCT and an observational study in tandem, it’s been suggested to analyze both study designs as part of a larger meta-analysis, as each study design brings with it a different perspective and interpretation (Faraoni & Schaefer, 2016). Instead of looking at RCTs and observational studies as being in opposition to one another, we can look at both study designs as supplementary to one another (Luthra & Taggart) and can help illustrate a more detailed understanding of patient care.

 

Luthra, S. & Taggart, D. (2016). Can the sum of pooled data from observational studies better evaluate outcome measures for the therapies in coronary artery disease? Expert Review of Cardio

Schaefer, S.T. & Faraoni, D. (2016). Randomized controlled trials vs. observational studies: Wjhy not just live together? BMC Anesthesiology, 16, 102.


Re: Real World Effectiveness of Meds for Bipolar disorder

by Abigail -

I was reading through these comments before posting my own to be sure I wasn't repeating information, but you have all covered so many points, that it's difficult to not repeat!

Alexa, I appreciate that you brought up the double sword suicide concerns. The psychiatrist I worked with during our second year was very careful to point this out to me. We will need to be especially cautious and thorough with our suicide assessments (always, but especially when making joint decisions with patients about medications) when considering Lithium due to its toxicity. It will be interesting to see how this plays out in clinical practice. I anticipate being much more comfortable prescribing Lithium to a chronically suicidal patient who is currently low risk versus high risk and more comfortable starting it for a hospitalized patient for monitoring and stabilization.

Another Lithium concern/consideration is patient fluid status, which is a valid concern for all patients, but especially those without stable housing and/or those with substance use disorders. And there are also important considerations such as interactions with commonly prescribed medications (basically any meds that can alter renal function, water or salt balance) and adherence.

As an aside, here are some thoughts and questions I have after reading this article:

  • Why was quetiapine the most commonly prescribed antipsychotic?

  • I wonder if the results for LAIs would have been different if the study started later? The authors mention the number of LAIs prescribed in the study was low, which isn’t surprising since the study period was 1987-2012 and long acting SGAs were not available until the early-mid 2000s and later.

  • It would be interesting to learn more about why patients taking benzos experienced higher rates of both psychiatric hospitalizations and all cause hospitalizations.


References:

Lahteenvuo, M., Tanskanen, A., Taipale, H., Hoti, F., Vattulainen, P., Vieta, E., and Tiihonen, J. (2018). Real-World effectiveness of pharmacologic treatments for the prevention of rehospitalization in a Finnish nationwide cohort of patients with bipolar disorder. JAMA Psychiatry, February 28, 2018. doi: 10.1001/jamapsychiatry.2017.4711.

https://www-uptodate-com.ucsf.idm.oclc.org/contents/bipolar-disorder-in-adults-and-lithium-pharmacology-administration-and-side-effects?search=lithium%20adherence&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1



Re: Real World Effectiveness of Meds for Bipolar disorder

by Diane Kim -
I have very much enjoyed reading fellow classmates’ posts on this interesting article. I especially appreciated thoughts around observational studies versus RCTs, including Lauren’s comments on the utilization of both study designs as being supplementary to one another and Sareen’s comments that observational studies should not be deemed “less rigorous,” but rather, they help us understand our patients in their natural environment. As this journal club and completion of the comprehensive exam has taught us, despite RCT’s being considered the gold standard in measuring data and outcomes, we must still be careful in interpreting results, which can often be quite biased. 


This concept led me to ponder the question of bias in medicine from a broader perspective and how biased trials may inform the way in which we practice medicine. Every-Palmer and Howick (2014) discussed this very phenomenon and the problematic ways in which many intervention studies are industry funded. The authors concluded by stating that many trials with “unfavourable” outcomes are often not published. Thus, the articles that DO get published are essentially, selectively chosen because they portray the “product” in a marketable and “favourable” light— which brings up questionable ethical practices. Unfavorable outcomes are just as important as favorable outcomes and consumers deserve to know what works AND what doesn’t work — and why. However, what investors will allow for unfavorable outcomes to be published about a product they are trying to sell? It’s not what realistically happens in this capitalist-driven system. What we need are more non-industry driven articles to eliminate bias-- however-- this requires funding that is already limited due to limitations in government resources. A shift towards socialized medicine is key -- and as a society, it is important to think about how we can move in that direction.


Additionally, while these authors are New Zealand based, this leads me to ponder the number of industry-funded versus non-industry-funded studies that exist in the United States (or other parts of the world). This class has helped me reinforce the importance of looking at the fine print at the end of the article and seeing which parties are involved with publication of the article and interpreting results with a “grain of salt,” if you will. 


References 

Every‐Palmer, S., & Howick, J. (2014). How evidence‐based medicine is failing due to biased trials and selective publication. Journal of evaluation in clinical practice, 20(6), 908-914.