Antidepressant Monotherapy in Bipolar Disorder: Prescription Patterns

By Lalit Baveja and Shivangi Sharma

4 April 2019

Practical Analytic Approaches to Healthcare Challenges

Mental disorders are considered among the leading causes of ill health and disability worldwide. The United States spends an estimated $201 billion on mental disorders, making it the most costly medical condition in the country.1 Bipolar disorder is a common mental health condition, and the US has the highest lifetime rate of bipolar disorder at 4.4%, according to the National Institute of Mental Health.2 Bipolar disorder causes significant social, economic and emotional problems for affected individuals, their caregivers, and society.

Treatment and management for bipolar disorders are fairly well established. The American Psychiatric Association recommendation for treatment of bipolar disorder includes medications such as mood stabilizers, anticonvulsants or antidepressants depending on the specific symptoms.3 Guidance for the appropriate combination of more than one medication is well documented. For example, The International Society for Bipolar Disorders and the National Institute of Mental Health recommend that antidepressant monotherapy should not be used in bipolar disorder patients because of the potential risk for excessive mood elevation or mood destabilization. Antidepressants should be used sparingly, and if antidepressants are used at all, they should be combined with a mood stabilizer.2, 4 Taking an antidepressant without a mood stabilizer is likely to cause unfavorable (i.e., more challenging and costly) outcomes, including rapid and frequent mood swings and higher tendency for suicide.

To determine the extent of compliance with established treatment guidelines, we conducted a study of prescription patterns for antidepressant medications in patients with bipolar disorder using claims data for a US health plan with approximately 2 million members. To measure inappropriate and potentially wasteful antidepressant monotherapy, MedInsight’s Health Waste Calculator application was used on claims data for the time period between January 2015 and December 2015. A key focus of analysis was to identify any antidepressant monotherapy prescription which is considered inappropriate and potentially harmful.

The MedInsight Health Waste Calculator application identified 2,139 members with an antidepressant prescription and a corresponding diagnosis of a bipolar disorder. Of the total members, 1,711 members had a concurrent prescription of a mood stabilizer hence were considered as not receiving antidepressant monotherapy. A total of 438 members or 20% of the total members (with 16% of the total services) were identified who had antidepressant monotherapy only. The utilization/cost of antidepressant monotherapy for these members was identified as clinically inappropriate and potentially harmful which are considered wasteful by the MedInsight Health Waste Calculator application.

Figure 1: Profile of Antidepressant Prescription Services in Bipolar Disorder

Amongst the wasteful population, 60% of the population were prescribed Selective Serotonin Reuptake Inhibitors (SSRIs) or Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs), which have been linked to heightened risk of subsequent mania (Figure 1). 5

Further analysis of the follow-up impact of antidepressant monotherapy highlighted that members in the Wasteful population had 50% more frequent psychotherapy visits than the Not Wasteful population.

Although claims data are limited in the ability to quantify downstream effects of inappropriate antidepressant monotherapy (such as mania), the results of this study confirm the prevalence of ineffective prescription patterns that are contrary to established treatment guidelines and result in wasteful spending and potential harm to patients.

1 Charles Roehrig. Mental Disorders Top The List Of The Most Costly Conditions In The United States. Available at

2 Bipolar Disease. National Institute of Mental Health. Available at

3 American Psychiatric Association. Bipolar Disorder. Available at

4 Pacchiarotti I, Thase M., et al, The International Society for Bipolar Disorders (ISBD) Task Force Report on Antidepressant Use in Bipolar Disorders. Am J Psychiatry. November 2013, 170:1249–1262.

5 Patel R, Reiss P, Shetty H, Broadbent M, Stewart R, McGuire P, Taylor M. Do antidepressants increase the risk of mania and bipolar disorder in people with depression? A retrospective electronic case register cohort study. Online First. Available at:

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