Mood Stabilisers – An Effective Option for Older Adults
Two standard medications for bipolar disorder were effective in controlling symptoms at doses tailored to older people in a clinical trial of treatment in adults over age 60. The findings are an important step towards filling an existing gap in evidence-based guidance for treatment of bipolar disorder in older adults.
People with bipolar disorder experience marked shifts in mood and energy; manic episodes are a hallmark of the illness. Mania is associated with severe disability and can be life-threatening. The disorder affects an estimated 2.6 percent of Americans, including older adults. While mood stabilising drugs can be very effective in treating mania, changes accompanying aging and co-occurring illness can make some older adults more susceptible to side effects of medications. Lithium, one of the medications tested in this study, is a mainstay drug for bipolar disorder, but older patients may not tolerate the doses used in younger individuals. This study sought to provide information on the effectiveness of lithium or a traditional alternative, divalproex, in older adults.
The multi-center Geri-BD study is the first randomised clinical trial of treatment of bipolar mania in older adults. Robert C. Young, M.D. at Weill Cornell Medicine and New York Presbyterian Hospital led the study, which followed 224 individuals over 60 years old with bipolar mania for nine weeks. Each participant was randomly assigned to either lithium or divalproex; the trial was double blind (neither participants nor experimenters knew which medication an individual was assigned during the course of the trial). If the assigned medication failed to adequately control symptoms, the participant could receive add-on risperidone, an antipsychotic medication.
Lithium and divalproex were both effective in controlling manic signs and symptoms. Lithium was more effective in reducing symptoms, but rates of response (a 50 percent reduction in the score on a standard rating scale of mania) and remission (a drop in score on the rating scale to below 9, compared with an average at baseline of 26.3) were similar. At nine weeks, 78.6 percent of participants who completed the study had responded to lithium and 73.2 percent to divalproex. The rates of remission were 69.6 percent and 63.4 percent. Less than 20 percent of participants needed to take an antipsychotic medication in addition to lithium or divalproex.
The authors point out that the rates of response and remission were similar to outcomes reported in younger patients even though doses and blood level targets in this study were lower than what is standard for younger patients.
“In general, treatment adequacy may be limited by side effects, and you can’t benefit from a treatment unless you can tolerate it,” says Dr. Young. This study’s findings were reassuring with respect to lithium as well as divalproex. There was no difference between lithium and divalproex in ratings of sedation. Participants taking lithium were more likely to have tremor, but a similar percentage of participants on both drugs were able, over the nine weeks of the study, to take enough of the medications to reach target levels. Less than 20 percent of participants needed to take additional antipsychotic medication. Minimizing the use of anti-psychotic medications avoids sometimes serious side effects.
Young RC, Mulsant BH, Sajatovic M, Gildengers AG, Gyulai L, Al Jurdi RK, Beyer J, Evans J, Banerjee S, Greenberg R, Marino P, Kunik ME, Chen P, Barrett M, Schulberg HC, Bruce ML, Reynolds CF, Alexopoulos GS, for the GERI-BD Study Group. GERI-BD: A Randomized double-blind controlled trial of lithium and divalproex in the treatment of mania in older patients with bipolar disorder .