Screen Shot 2016-06-12 at 3.57.08 PMHow many meds do you use to treat your bipolar disorder?  And your co-morbid afflictions?  Personally, I get off easy and take only four.

In the treatment of bipolar disorder, polypharmacy (the use of multiple meds to treat a disease or disorder) is the norm.  And generally, bipolar I patients take more meds than their bipolar II brethren.  When I began treating the whole spectrum of the disease (instead of just the depressions), what made me angry was not having bipolar, but having to swallow handfuls of pills several times a day for the rest of my life.

Did you know that prescribing multiple meds for the treatment of bipolar disorder is not an evidence-based practice? And in a recent study of 230 patients who took four or more psychotropic meds, 36% of them were taking medications that affected their behavior and mental state.  A few other studies go on to claim there are no clinical trials that examine which medications can be prescribed together effectively for the treatment of BP.  Which in essence is true; most likely the interaction and efficacy of the combination of meds we swallow each day has never been tested or vetted by an agency like the FDA.

Keeping to the theme of polypharmacy, a study published last May by the International Journal of Bipolar DisordersDrug treatment patterns in bipolar disorder: analysis of long-term self-reported data isn’t a clinical trial of any combination of meds, however the conclusions one can draw after examining data from this study of patient reported data is worthy of note.  Here is an excerpt from the Results and Discussion section:

Four hundred fifty patients returned a total of 99,895 days of data (mean 222.0 days). The most frequently taken drugs were mood stabilizers. Of the 450 patients, 353 (78.4%) took a stable drug combination for ≥50% of days. The majority of patients were taking polypharmacy, including 75% of those with a stable combination. Only a small number of drugs were commonly taken within each medication class, but there were a large number of unique drug combinations: 52 by medication class and 231 by specific drugs. Eighty percent of patients with a stable combination were taking three or less drugs daily. Patients without a stable combination took drugs but made frequent changes. Taking more than one drug within a medication class greatly increased the drug load.

To summarize, (1) patients were more likely to take a mood stabilizer than any other drug; (2) although most patients were taking polypharmacy, there were no predominant drug regimens even among those taking a stable combination; and (3) most patients with a stable combination take a relatively small number of drugs daily. The wide variation in drug regimens and numerous possible drug combinations suggest that more evidence is needed to optimize treatment of bipolar disorder.

[Italics and highlight are mine.]

For those interested, the Background and Medication Classes sections are worth a read as well.

But the meat in this study appears in two tables: Table 4 Most frequent stable combinations by medication class (N = 353), Combinations by class) and Table 5 (Most frequent stable combinations by specific drug (N = 353)).  Note these tables are not the results of actual clinical trials held to demonstrate efficacy of each drug combination. But the mere act of collating this type of data scratches the surface of the problem.  Wouldn’t it be great if researchers could drill down further into this overall concept and launch more granular studies that deal with a better defined set of specifics about polypharmacy and bipolar disorder?

Although this study is moving in the right direction, it was even performed by an international team, I doubt our prayers will be answered for several reasons.  For example, there are a myriad of  psychotropic drugs that would have to be studied.  Even if the 10 meds listed under the Monotherapy category in Table 5 were all that were studied and then only 50% of the the possible permutations were initially examined…I’ll stop there.  Another reason is big pharma would never allow it.  The industry sponsors 90% of clinical trials. Imagine what would happen if ‘competing’ manufacturers were to get into the ring together?  Which they surely would have to do if a true, clinical trial using only one of us were launched.


Because I’ve had an overly stressful week and had to rely on more med than I would have liked, I’m going to add a bonus, concluding paragraph fraught with pessimism and a touch of maudlin.  I don’t think the reigns on a polyparmacy approach to treating bipolar disorder will be pulled in during my lifetime.  First and foremost, it’s a business decision.  We are cash cows to the pharmaceutical companies. No one is going to willingly sponsor a clinical trial that could potentially put them out of business.  And bipolar disorder is not understood well enough yet to justify a treatment approach that will veer away from the rut of polypharmacy.  Strides have been made in the last few years with studies in genetics and brain imaging, but it’s not enough to make a difference to me in the here and now.  And, when I’m in a particularly resentful mood (such as right now, as I swallow a gulp of tea and yet another alprazolam) something my Mother used to say comes shooting back into my almost manic thoughts.   She died of non-small cell lung cancer.  A particularly unpleasant way to go.  She chose chemo and suffered through the treatment to prolong her life for three more years after diagnosis.  She always used to say, “It’s barbaric, the way we treat cancer.  The doctors pump you full of toxins until you’re at the brink of death, then pull you back just enough to keep you alive.”  I don’t have cancer.  I have no clue what she or anyone else who has had any form of the disease goes or has gone through.  But when the idea that polypharmacy to treat bipolar disorder is not evidence-based is printed in black and white in front of me?  I wish my Mother were still around to share my stories with.  Not for the obvious reason that I will miss her every day for the rest of my life, but because she is one of the few people who’s graced my life that would truly understand how I was ‘polypharmacied’ to the edge of my sanity and then brought back just as I was about to break for good.