A third of patients who go to the hospital for bipolar I disorder are on four (or more) psychiatric medications—despite a lack of evidence that’s a good idea.

This highlights the 4.4 percent of the U.S. has bipolar disorder, as best we know. The global rate is about half that, though detection and diagnosis vary dramatically. Still, treatment for the millions of people with the at-times debilitating condition involves an impressive degree of trial and error amid arrays of pills.

This week in the journal Psychiatry Research, doctors at Brown University published their findings that more than a third of people with bipolar I disorder who were admitted to a psychiatric hospital in Rhode Island were taking four or more psychiatric medications.

Dr. Lauren Weinstock, an assistant professor of psychiatry and human behavior and the study’s lead researcher, said the findings “reflect the enormous challenge of symptom management.”

Percentage of bipolar patients on multiple medications (Brown)

The study notes that between 1974 and 1996, patients treated at the National Institutes of Mental Health given three or more psychotropic medications increased thirteen-fold. In 1996 a journal article on the understanding at the time concluded, “Further research is necessary to formally evaluate whether these drug combinations are more effective than [a single drug].”

Between 1996 and 2006 the average number of prescriptions continued to increase, 40 percent over that decade. The number of patients on three or more psychotropic medications more than doubled. All of this happened without clinical research to show that combining three or more medications was effective.

When medications are added to other medications, it can be hard to know which effects are due to which medication. If we replace one of the medications, will all the cards fall? Is this completely safe in the long term? We do know that the practice, known within the medical community as polypharmacy and sometimes defended in literature as a “necessary evil,” costs money and increases potential for drug interactions and side effects. As Weinstock said in the university’s press release, “By definition that’s not evidence-based treatment.”

Evidence-based treatment is the buzzword movement aimed at getting doctors to only do things that are supported by sound research.

Medication for bipolar disorder can work, can be wonderful. If studies find prescribing four or five or seven medications is sometimes prudent and necessary, then that will be that. It’s not ideal to ask anyone to remember to take that many pills, especially in cases of mental health that may involve flights of mania wherein a person feels invincible and is buying yachts on credit, alternating with periods of major depression wherein getting to a pharmacy to fill and orchestrate a half dozen prescriptions can be an insurmountable proposition. Not to mention the psychology of it. Look how many pills you require. But at least as patients and doctors we’d have the reassurance that it’s proven to work.

Given the scale and nature of the disorder, that kind of science should be a priority. “Without many treatment alternatives,” Weinstock said, “this is where we are as a field.”

Written by James Hamblin and published by The Atlantic, February 5, 2014.

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