Antipsychotic Reduction in Bipolar Disorder, Depression: Higher Healthcare Burden
Clinicians should take into account the possibility of relapse in patients with BD and MDD when reducing antipsychotic dosing as part of the treatment strategy.
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NEW ORLEANS — Reducing doses of antipsychotics in patients with bipolar disorder (BD) or major depressive disorder (MDD) may result in higher rates of inpatient and psychiatric admissions and emergency room (ER) visits, according to research presented at the 2017 Psych Congress, held September 16 to 19.
This retrospective study conducted by a team of researchers led by Sanjay Gandhi, PhD, from the Global Health Economics Department at Teva Pharmaceuticals in Frazer, Pennsylvania, sought to determine the healthcare burden associated with reducing antipsychotic dosing in patients with BD or MDD. The team used rates of all-cause and mental health-related hospitalization and ER visits as an indicator.
Using Medicaid data from 6 states (Iowa, Kansas, Mississippi, Missouri, New Jersey, and Wisconsin) collected between 2008 and 2017, the researchers studied patients ≥18 years with a diagnosis of either BD (n=23,992, 37.8% male) or MDD (n=17,776, 33.5% male) and ≥2 oral antipsychotic prescription fills following diagnosis. They reviewed the data of patients on antipsychotic monotherapy for whom the medication dose had been reduced by ≥10%, and compared it with that of patients on a stable dose for ≥91 days (number-, age-, and gender-matched controls). Patients were followed for 1 year after initial dose reduction for cases, and for 1 year after first refill following the 90-day stable dose period for controls.
Dose reductions were similar for the 10 most commonly prescribed antipsychotics (including quetiapine, aripriprazole, and risperidone) in the cohort of study participants with BD or MDD. Patients who had experienced a ≥10% antipsychotic dose reduction had higher rates of inpatient admissions compared with controls (for BD: hazard ratio [HR], 1.17; 95% CI, 1.12, 1,23; P <.001; for MDD: HR, 1.11; 95% CI, 1.05, 1.16; P <.001), as indicated by a cox regression analysis. Similar results were found for ER visits and psychiatric admission for ≥10% and ≥30% dose reductions in patients with BD or MDD, compared with their counterparts on stable-dose antipsychotics (P <.001 for all).
Among patients with BD, those with a ≥10% dose reduction demonstrated a first-year event rate of 52.1% vs 49.9% for controls (HR, 1.09; 95% CI, 1.05, 1.13); P <.001). For patients with MDD, those with a ≥10% dose reduction had a first-year event rate of 51.1% vs 50.2% for controls (HR, 1.07; 95% CI, 1.02, 1.11; P <.01).
Patients with BD experiencing a ≥10% dose reduction were significantly more likely to have an inpatient admission or ER visit for mental health-related diagnoses than the control group (19.2% for a first-year event rate vs 15.9% in the control cohort; HR, 1.22; 95% CI, 1.15, 1.31; P <.001). The first-year event rate for a psychiatric-related diagnosis in the BD group was 36.0% in the ≥10% dose-reduction cohort compared with 32.1% in controls (HR, 1.19; 95% CI, 1.13, 1.24; P <.001).
Patients with MDD with ≥10% dose reductions were significantly more likely to have an inpatient admission or ER visit for mental health-related diagnoses than the control group. The first-year event rate for an MDD-related diagnosis in the ≥10% dose-reduction group was 11.8% compared with 10% in the control cohort (HR, 1.22; 95% CI, 1.11, 1.34; P <.001). Additionally, the first-year event rate for a psychiatric-related diagnosis in the MDD group was 32.6% vs 30.1% in the control cohort (HR, 1.17; 95% CI, 1.11, 1.23; P <.001).
These results indicate that patients with BD or MDD experiencing antipsychotic dose reductions have significantly higher rates of all-cause and mental health-related hospitalization and ER visits compared with patients on a stable dose. The researchers suggest that “Treatment strategies in which antipsychotic dosing is lowered in order to reduce [tardive dyskinesia] symptoms, or for other reasons, should take into account the potentially harmful effects of relapses on patients with BD and MDD.”
Dr Gandhi is an employee of Teva Pharmaceutical Industries.
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Carroll B, Mu F, Ayyagari R, Gandhi S. Hospital utilization rates following antipsychotic dose reductions among patients with bipolar and major depressive disorders. Poster presentation at: Psych Congress; September 16-19, 2017; New Orleans, LA.