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Original Investigation |

Self-harm, Unintentional Injury, and Suicide in Bipolar Disorder During Maintenance Mood Stabilizer Treatment A UK Population-Based Electronic Health Records Study

Joseph F. Hayes, MSc, MBChB1; Alexandra Pitman, PhD1; Louise Marston, PhD2; Kate Walters, PhD2; John R. Geddes, MD3; Michael King, PhD1; David P. J. Osborn, PhD1
[+] Author Affiliations
1Division of Psychiatry, University College London, London, England
2Department of Primary Care and Population Health, University College London, London, England
3Department of Psychiatry, University of Oxford, Oxford, England
JAMA Psychiatry. 2016;73(6):630-637. doi:10.1001/jamapsychiatry.2016.0432.
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Importance  Self-harm is a prominent cause of morbidity in patients with bipolar disorder and is strongly associated with suicide. There is evolving evidence that lithium use may reduce suicidal behavior, in addition to concerns that the use of anticonvulsants may increase self-harm. Information is limited about the effects of antipsychotics when used as mood stabilizer treatment. Rates of unintentional injury are poorly defined in bipolar disorder, and understanding drug associations with this outcome may shed light on mechanisms for lithium’s potential antisuicidal properties through reduction in impulsive aggression.

Objective  To compare rates of self-harm, unintentional injury, and suicide in patients with bipolar disorder who were prescribed lithium, valproate sodium, olanzapine, or quetiapine fumarate.

Design, Setting, and Participants  This investigation was a propensity score (PS)–adjusted and PS-matched longitudinal cohort study in a nationally representative UK sample using electronic health records data collected between January 1, 1995, and December 31, 2013. Participants included all patients diagnosed as having bipolar disorder who were prescribed lithium, valproate, olanzapine, or quetiapine as maintenance mood stabilizer treatment.

Main Outcomes and Measures  The primary outcome was any form of self-harm. Secondary outcomes were unintentional injury and suicide.

Results  Of the 14 396 individuals with a diagnosis of BPD, 6671 were included in the cohort, with 2148 prescribed lithium, 1670 prescribed valproate, 1477 prescribed olanzapine, and 1376 prescribed quetiapine as maintenance mood stabilizer treatment. Self-harm rates were lower in patients prescribed lithium (205; 95% CI, 175-241 per 10 000 person-years at risk [PYAR]) compared with those prescribed valproate (392; 95% CI, 334-460 per 10 000 PYAR), olanzapine (409; 95% CI, 345-483 per 10 000 PYAR), or quetiapine (582; 95% CI, 489-692 per 10 000 PYAR). This association was maintained after PS adjustment (hazard ratio [HR], 1.40; 95% CI, 1.12-1.74 for valproate, olanzapine, or quetiapine vs lithium) and PS matching (HR, 1.51; 95% CI, 1.21-1.88). After PS adjustment, unintentional injury rates were lower for lithium compared with valproate (HR, 1.32; 95% CI, 1.10-1.58) and quetiapine (HR, 1.34; 95% CI, 1.07-1.69) but not olanzapine. The suicide rate in the cohort was 14 (95% CI, 9-21) per 10 000 PYAR. Although this rate was lower in the lithium group than for other treatments, there were too few events to allow accurate estimates.

Conclusions and Relevance  Patients taking lithium had reduced self-harm and unintentional injury rates. This finding augments limited trial and smaller observational study results. It supports the hypothesis that lithium use reduces impulsive aggression in addition to stabilizing mood.

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Figure 1.
Flow Diagram of Patient Selection

Mood stabilizer is defined as antipsychotic or anticonvulsant medication.

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Figure 2.
Cumulative Self-harm Rate in Patients Prescribed Lithium vs Valproate, Olanzapine, or Quetiapine

Shown are unadjusted Kaplan-Meier estimates of cumulative self-harm, with shaded areas showing 95% CIs.

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