From the Editor

What’s the best medication for bipolar disorder? Today, we have a variety of options from the old (lithium) to the new (modern antipsychotics). But what to prescribe?

In the first selection from The British Journal of Psychiatry, Cecilie Fitzgerald (of the Danish Research Institute for Suicide Prevention) and her co-authors try to answer these questions with a cohort study including those diagnosed with bipolar and living in Denmark between 1995 and 2016. They employ two types of analyses and focus on suicide, self-harm, and psychiatric hospital admissions. They conclude: “Although confounding by indication cannot be excluded, lithium seems to have better outcomes in the treatment of bipolar disorder than other mood stabilisers.” We consider the paper and its implications.

Lithium: not just for Teslas?

In the second selection, Stef Kouvaras (of the South London and Maudsley NHS Foundation Trust) and her co-authors consider a single-session psychotherapy intervention for an inpatient unit. In this recently published brief report for Psychiatric Services, they do a feasibility and acceptability study of positive psychotherapy. “The findings of this study indicate that positive psychotherapy is feasible and acceptable on acute psychiatric wards and that service users with severe and complex mental health conditions find the intervention helpful.”

In the final selection, executive coach Brad Stulberg writes about his experiences with OCD for The New York Times. He notes that his diagnosis helped him find care – but he worries about labels. “The stigma around mental illness has certainly not disappeared. But increasingly, mental health diagnoses are being embraced as identity statements.”


Selection 1: “Effectiveness of medical treatment for bipolar disorder regarding suicide, self-harm and psychiatric hospital admission: between- and within-individual study on Danish national data” 

Cecilie Fitzgerald, Rune Haubo Bojesen Christensen, Jerome Simons, et al.

The British Journal of Psychiatry, 22 April 2022  Online First

Bipolar disorder has an estimated lifetime prevalence of 4.4%. The life expectancy of persons with bipolar disorder has been shown to be considerably reduced compared with the general population, with suicide being one of the leading causes of premature death. Further, people with bipolar disorder have been reported as having an 11-fold higher risk of suicide and an 18-fold higher risk of self-harm (intentional non-fatal self-poisoning and self-injury) compared with the general population. In addition, relapse of the disorder frequently necessitates psychiatric hospital admission.

Mood stabilisers can prevent suicidal behavior. Meta-analyses of randomised controlled trials suggest that lithium might be the most effective drug for preventing relapses and suicide deaths among people with bipolar disorder. However, the current body of evidence is restrained by exclusion of persons with suicidal ideation from clinical trials. Recent studies suggest a substantial reduction in the use of lithium, which could be attributed to risks of relapse and suicidal behaviour when patients discontinue treatment, and adverse effects during treatment. These effects, however, might be comparable to those of other mood stabilisers. Also, observational studies may be biased by clinicians’ preference for prescribing lithium to persons with severe bipolar disorder and high adherence to treatment. Furthermore, only a few drugs have been assessed.

Here’s what they did:

“A cohort design was applied to people aged ≥15 years who were diagnosed with bipolar disorder and living in Denmark during 1995–2016. Treatment with lithium, valproate, other mood stabilisers and antipsychotics were compared in between- and within-individual analyses, and adjusted for sociodemographic characteristics and previous self-harm.”

Here’s what they found:

  • “A total of 33 337 persons (59.8% female) were diagnosed with bipolar disorder (mean age 54.7 years…) between 1995 and 2016.” 
  • Follow up. “These were followed over 266 779 person-years, of which individuals spent 145 899 person-years (54.7%) receiving treatment with mood stabilisers and 120 880 (45.3%) person-years not receiving treatment.”
  • Medication choices. “Allowing for multi-drug use, the largest number of individuals were treated with lithium (68 675 person-years, 25.7%), followed by antipsychotics (44 889 person-years, 16.8%), other mood stabilisers (36 055 person-years, 13.5%) and valproate (14 723 person-years, 5.5%). Mean treatment lengths ranged from 148 to 238 days, and mean number of treatment periods from 10 to 14.”
  • Suicide. “When compared with individuals not receiving treatment, those receiving lithium had a lower rate of suicide (hazard ratio 0.40…).”
  • Self-harm. “When comparing treatment and non-treatment periods in the same individuals, lower rates of self-harm were found for lithium (hazard ratio 0.74…).” See figure below.
  • Admissions. “Lower rates of psychiatric hospital admission were found for all drug categories compared with non-treatment periods in within-individual analyses (P<0.001).”
  • “The low rates of self-harm and hospital admission for lithium in within-individual analyses were supported by results of between-individual analyses.”

The authors write:

“Using different analytic strategies, precise measures for treatment lengths and extensive sensitivity analyses, we found that treatment with lithium was associated with lower rates of suicide, self-harm and psychiatric hospital admission compared with no treatment. The majority of examined drugs were associated with lower rates of psychiatric hospital admission compared with no treatment. The favourable results for lithium for all three outcomes found in the between-individual analyses were confirmed in the within-individual analyses.”

A few thoughts:

1. This is an impressive paper. 

2. Drawing on Danish databases, they used data covering more than 33,000 people with bipolar disorder. (!!)

3. The clinical implications? Five words: Lithium is an underappreciated medication. The authors argue as much: “Our finding that lithium is associated with better outcomes for persons with bipolar disorder than other drug therapies is in accordance with previous findings. Yet, the use of lithium is declining in some high-income countries. This might be because lithium has been linked to adverse outcomes after ending treatment, which could lead practitioners to use alternatives. In this study, we did not find differences in this respect when compared with other treatments, which is supported by other investigations.”

4. This paper draws on significant statistical analyses that are only superficially covered here. Note that the analyses included a “within-individual comparison” – that is, “a novel methodological approach, which compares periods on and off medication for the same individual, as a means of evaluating comparative drug effectiveness.” Again, this is an impressive paper and this is an impressive statistical analysis.

5. They authors note several limitations, including with the data itself. “Although registration of suicides in Denmark is regarded as being reliable, self-harm episodes may be underreported by up to 30%.”

6. Still, the study is consistent with other work in the area. Decades after psychiatrist John Cade first experimented with it for his patients, lithium remains an important part of treatment.

The full British Journal of Psychiatry paper can be found here:

Selection 2: “Character Strength–Focused Positive Psychotherapy on Acute Psychiatric Wards: A Feasibility and Acceptability Study

Stef Kouvaras, Martina Guiotto, Beate Schrank, et al.

Psychiatric Services, 5 April 2022 Online First

Acute psychiatric wards offer a therapeutic space for people with severe and complex mental health conditions. Although medication-based treatment is very prevalent on these wards, psychological input is necessary to stabilize patients experiencing crisis and distress, but such input needs to be provided efficiently and cost-effectively. Studies indicate that adapted group-based psychological interventions are feasible and effective in inpatient settings, and given the resource challenges associated with implementing psychological therapies on acute psychiatric wards, a need exists for innovative approaches.

Positive psychotherapy emphasizes strengths and positive well-being and can have a positive impact on recovery. Well-being is rarely foregrounded in severe mental illness; however, findings with positive psychology and from well-being research in psychosis indicate that a focus on well-being is feasible and associated with remission of psychiatric symptoms. Character strengths are popular components of positive psychotherapy, and in psychosis, a focus on strengths such as honesty, authenticity, and genuineness can have several benefits. A manualized intervention of positive psychotherapy for psychosis delivered in a group format was found to be feasible and acceptable and to improve mood.

So begins a brief report by Kouvaras et al.

Here’s what they did:

“Participants were invited in 2018–2019 to identify positive experiences, link them to a personal character strength, and plan a strengths-based activity. The intervention’s feasibility was evaluated through fidelity to session components, character strengths identification, and activity completion. Acceptability was evaluated with self-reported pre- and postsession mood ratings, a postsession helpfulness rating, and narrative feedback.”

Here’s what they found:

  • 70 participated in this study.
  • Sessions. Most (79%) attended a session once. 
  • Demographics. The participants’ mean age was 37.1 and 66% were women; 43% identified as White. 
  • Diagnosis. 39% had a diagnosis of schizophrenia, schizotypal, or delusional disorder; 21%, adult personality and behavior disorders; and 21%, mood disorders.
  • 80% identified a character strength; of these, 71% identified a strengths-based activity, and of these, 58% carried out the activity. Most commonly reported: kindness at 20%, self-regulation, 11%; creativity, 11%; love of learning, 9%; and perseverance, 9%.
  • The mean helpfulness rating was 8.5 (on a 10-point Likert scale), and positive mood significantly increased post-session (5.9 pre-session vs. 7.2 post-session).

A few thoughts:

1. Obviously, this is early data – just 70 participated.

2. Still, the intervention was helpful.

3. The concept of a one-session therapy is very attractive on an inpatient basis, where admissions are often short and multiple sessions may be impractical.

The full Psychiatric Services brief report can be found here:

Selection 3: “My O.C.D. Diagnosis Was a Blessing, Until It Became Too Central to My Identity”

Brad Stulberg

The New York Times, 3 July 2022

Five years ago, seemingly out of nowhere, my brain fell into an abyss of unrelenting intrusive thoughts – What if I harm myself? What if I harm others? What if I’m crazy? – each of which was accompanied by electric shocks of anxiety and full-on sensations of dread. It was, by far, the most terrifying, vexing and isolating period of my life. My first moment of relief came four weeks later, when I finally got in to see a psychiatrist.

’You aren’t suicidally depressed or experiencing psychosis,’ he told me. ‘You’ve got a severe case of obsessive compulsive disorder.’

At first, the label was helpful.

So begins an essay by Stulberg.

He writes about his diagnosis and how it helped him feel better: “I went from drowning in a bottomless and unexplainable sea of terror to ‘having O.C.D.’ The label helped me make sense of my reality, pointed the way to a specific type of treatment (something called ‘exposure and response prevention’) and made me feel less alone.”

That said, he soon finds the label to be problematic:

“But as time passed, identifying too closely with O.C.D. began to impede upon my progress toward feeling like myself again. As I embraced the idea of myself as a person with O.C.D., it came to dominate my thinking, overshadowing other aspects of my identity. The majority of my writing was about O.C.D. I’d work out to help my O.C.D. I felt impostor syndrome in my work as a coach because of my O.C.D. It affected my parenting, as I became worried my child would have O.C.D. too.”

He recognizes that labels can be important: “If a label makes people feel less alone – or even joyful at having a name to put to their discomfort and a community to identify with, as the actress Rachel Bloom sings of in a musical number about her character getting a borderline personality disorder diagnosis, from the TV comedy ‘Crazy Ex-Girlfriend’ – then that, too, is positive.”

But he wonders if we may be “fixating” on labels, and makes a couple of comments: 

  • “There’s a flattening of people’s unique or individual experiences. Just about anything can – and often does – fall under large umbrella terms such as ‘trauma,’ as Parul Sehgal wrote recently in The New Yorker. When we apply a category too broadly, it loses much of its meaning.”
  • “I’ve also noticed that when mental and emotional health labels are used casually, we all too often end up romanticizing mental illness – which, as anyone who has actually experienced it knows, is anything but romantic. In a 2018 essay in The Times, Rhiannon Picton-James wrote about $48 gold necklaces that spelled out ‘anxiety’ and ‘depression’ in trendy italic letters.”

He ends on a somewhat contradictory note:

“We need categories and labels. Without them, it’d be really hard to make sense of the world and ourselves. And also, the labels we use to describe ourselves are inherently reductionist. Both of these things can be true at once. As Walt Whitman wrote: ‘Do I contradict myself?/Very well then, I contradict myself./(I am large, I contain multitudes.)’”

A few thoughts:

1. This is a thoughtful essay.

2. It’s great to read the words of someone with lived experience on the opinion pages of The New York Times

3. The author describes well the importance of his diagnosis and yet his own ambivalence.

4. Not so long ago, we merged patients and their diagnoses – referring to a person with depression as a “depressive man,” for example. This essay is a nice reminder that people aren’t their diagnoses. 

The full NYT op ed can be found here:

Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.