For anyone living with bipolar disorder, or supporting a loved one through it, staying on medication long enough for it to work is often the hardest part of recovery. A large new study from China suggests this struggle is far more common than many realise, with more than four in ten newly diagnosed inpatients abandoning all pharmacological treatment within just twelve months.
The research, published in the Journal of Affective Disorders, followed 3,034 inpatients newly diagnosed with bipolar disorder in Beijing between 2010 and 2017. Using medical insurance claims data covering millions of residents, researchers tracked exactly what medications patients were prescribed, and what happened to their treatment over time.
The findings paint a picture of real world psychiatric care that often diverges from international guidelines. Over half of patients, 57.3%, started treatment on two or more psychotropic medications at once, a practice known as polypharmacy. Nearly a quarter began on three or more drugs simultaneously.
Quetiapine emerged as the most commonly prescribed antipsychotic, used by 43.8% of patients, while lithium, long regarded as the gold standard mood stabiliser for bipolar disorder, was prescribed to just 37.7%. Despite its proven effectiveness at preventing relapse and reducing suicide risk, lithium use remained relatively low and was used even less frequently in older adults.
Perhaps most striking was the discontinuation rate. By the end of the first year, 42.7% of patients had stopped all medication. Within the following year, that figure climbed further, with 47.2% of remaining patients also discontinuing treatment during the thirteen to twenty four month period.
Dr Martha Sajatovic, professor of psychiatry and neurology at Case Western Reserve University, who was not involved in the study, said: “Other study teams have also noted that approximately one in two individuals with bipolar disorder are non-adherent with medications prescribed for bipolar disorder, often leading to severe and negative consequences.”
Antidepressant use also raised concerns among the study’s authors. Around 18.1% of patients were prescribed an antidepressant within thirty days of diagnosis, and 44.2% used one at some point during follow up, despite clinical guidance generally cautioning against antidepressant use in bipolar disorder due to the risk of triggering manic episodes or destabilising mood.
The researchers noted that maintenance treatment, once patients did stay on medication, tended to rely heavily on antipsychotic monotherapy rather than the combination approaches recommended for long term relapse prevention. Lithium’s use in maintenance therapy was largely confined to combination treatment alongside quetiapine or olanzapine, rather than being used as a standalone option as guidelines suggest.
For mental health services and clinicians, these findings underline a persistent gap between evidence based recommendations and everyday clinical practice. Bipolar disorder is a lifelong, recurrent condition, and interruptions in treatment are strongly linked to relapse, hospitalisation and poorer long term outcomes.
Giulia P. Davis, a licensed marriage and family therapist and founder of Mycelia Therapy in San Francisco, who was not involved in the study, said: “Medication adherence may be recorded as an individual decision, but family relationships can play a big part in it. Someone might leave an appointment feeling confident about their treatment, then return home to a partner or parent who questions the diagnosis or believes they no longer need medication.”
The study’s authors called for greater clinician training on phase specific treatment strategies and renewed efforts to support patients through the difficult early months after diagnosis, when the risk of dropping out of care appears to be highest.
Davis added: “During the first year, clinicians could ask patients whether their families have concerns about the diagnosis or medication. With permission, speaking with relatives may help address misunderstandings before they become a barrier to care.”
