High Exposure to Neuroleptics in Bipolar Patients: A Retrospective Review
J Clin Psychiatry 2000;61(1):68-72
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Background: Acute and long-term use of
neuroleptics to treat bipolar disorder remains prevalent despite
safety concerns. Neuroleptic-treated patients with bipolar
disorder have been reported to have rates of tardive dyskinesia,
akathisia, and acute dystonia as high as or higher than patients
with schizophrenia. Moreover, the pattern of repeated,
intermittent use of neuroleptics in bipolar disorder may increase
rather than decrease the risk of tardive dyskinesia.
Method: Retrospective life charts of 133
treatment-refractory patients with bipolar disorder (diagnosed
according to Research Diagnostic Criteria or a clinical interview
with the Schedule for Affective Disorders and
Schizophrenia-Lifetime Version or the Structured Clinical
Interview for DSM-IV Axis I Disorders) admitted to the National
Institute of Mental Health (NIMH) were reviewed for prior
neuroleptic use, medication exposure, and course of illness
variables. Patients' medication response and degree of
improvement while at NIMH were also assessed.
Results: A total of 72.2% (N = 96) of the
bipolar patients examined had exposure to neuroleptics prior to
referral to NIMH. Neuroleptic-treated patients had a mean of 5.6
neuroleptic trials with a mean duration of 166.4 days for each
trial and a dose range of 25 to 960 mg in chlorpromazine
equivalents. Life chart data showed that the neuroleptic-exposed
and nonexposed bipolar patients were distinguished by 1
course-of-illness variable: increased suicidality in the
neuroleptic-treated group. Patients with and without prior
neuroleptic exposure experienced the same high degree of
improvement at discharge from NIMH. Only 12.5% (N = 12) of the
group previously treated with typical neuroleptics (N = 96)
required neuroleptics at discharge.
Conclusion: Our data suggest that the majority
of even treatment-refractory bipolar patients can be stabilized
without neuroleptics. Given the high risk of tardive dyskinesia
and the availability of other novel agents, the routine
intermittent use of typical neuroleptics to treat patients with
bipolar disorder should be minimized.