Abstract
To the Editor
Seventeen years ago we reported on the in-hospital clinical practices for the treatment of acute mania in a Brazilian institution (Volpe et al., 2003). Since then, new evidence has led to updated national and international treatment guidelines (i.e. Malhi et al., 2018; National Collaborating Centre for Mental Health, National Institute for Health and Clinical Excellence [NICE], 2018). However, the specific context of each countries’ public mental health care must be considered when formulating policy, resource allocation and treatment guidelines. Since scarce new naturalistic data have been produced, we aimed at describing the current pharmacological strategies for the inpatient treatment of mania in two major public Brazilian psychiatric hospitals.
Manic and mixed episodes (International Classification of Diseases, 10th revision [ICD-10]) represented 13.0% (346/2658) of all admissions in 2017. Those were acute hospitalizations (median 16 days) and mostly of female patients (55.7%), 40.4 ± 12.7 years old.
According to the electronic prescription records, 90.2% of cases received one or more mood stabilizers (Table 1). Valproate (72.0%) was more frequently used than lithium (59.8%) or carbamazepine (11.2%). Combined mood stabilizers were used in 25.2%. Antipsychotics were used in 93.1% of patients, mostly typical (88.4%) than atypical (11.6%), and combining typical + atypical in 6.9%. Benzodiazepines were more frequently used as adjunctive medication (82.9%) than antidepressants (11.6%). Polypharmacy was the main strategy (Table 2). Using one single major antimanic agent was infrequent (4.3%).
Frequency and daily dosages of prescribed medications for the inpatient treatment of acute mania in two public psychiatric hospitals of Minas Gerais, Brazil (N = 346).
SD: standard deviation.
Low potency antipsychotics were used at low dosages (<300 mg of chlorpromazine equivalents).
Specific treatment strategies: major antimanic agents used for the inpatient treatment of acute mania in two public psychiatric hospitals of Minas Gerais, Brazil (N = 346).
Excluding adjunctive medication (i.e. low-dose sedative antipsychotics, benzodiazepines, antidepressants, anticholinergics).
Current practices conflicted with the updated treatment guidelines (i.e. Malhi et al., 2018; National Collaborating Centre for Mental Health, NICE, 2018) regarding the preference for typical antipsychotics, the frequent use of drugs with anticholinergic effects (promethazine or biperiden, 59.8%), the adjunctive use of relatively low dosages of sedative antipsychotics (82.4%) and, less frequently, antidepressants (11.5%).
In the Brazilian public health system, risperidone, olanzapine, quetiapine and clozapine are available since 2016 exclusively for bipolar I outpatients. Their prescription requires additional periodical paperwork, which some physicians might not feel able or motivated to provide. In addition, atypical agents are only dispensed by central public pharmacies in major towns. This limits the post-discharge continuation strategies that involve atypical agents.
A striking difference from our previous result in a private hospital (Volpe et al., 2003) is the preference for valproate over lithium. Safe management of lithium levels is quite more challenging than anticonvulsants in the context of Brazilian public health. This includes patients’ low literacy, insufficient ambulatory staffing and limited access to laboratory tests.
The major finding on prescription patterns was a clear preference for combining antimanic agents. Future studies should assess the efficacy of different combinations and dosages, in order to provide supporting evidence to optimize treatment strategies, as well as compare prescribing practices between countries and analyze the reasons for eventual differences.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship and/or publication of this article.
