Self-harm, Unintentional Injury, and Suicide in Bipolar Disorder During Maintenance Mood Stabilizer Treatment A UK Population-Based Electronic Health Records Study
Self-harm, Unintentional Injury, and Suicide in Bipolar Disorder During Maintenance Mood Stabilizer Treatment A UK Population-Based Electronic Health Records Study
复制标题
DOI：
10.1001/jamapsychiatry.2016.0432
复制
发表时间：
2016-06-01
期刊：
影响因子：
25.8
通讯作者：
Osborn, David P. J.
中科院分区：
文献类型：
--
作者：
Hayes, Joseph F.;Pitman, Alexandra;Osborn, David P. J.
自我伤害是双相情感障碍患者发病的重要原因，并与自杀密切相关。越来越多的证据表明，使用锂盐可能会减少自杀行为，此外，人们还担心使用抗惊厥药可能会增加自残。关于抗精神病药物作为情绪稳定剂治疗效果的信息有限。双相情感障碍中意外伤害的发生率定义不清，了解药物与这一结果的关联可能会揭示锂通过减少冲动攻击而具有潜在抗自杀特性的机制。目的比较服用锂、丙戊酸钠、奥氮平或富马酸喹硫平处方的双相情感障碍患者的自残、意外伤害和自杀率。设计、环境和参与者本研究采用1995年1月1日至2013年12月31日收集的电子健康记录数据，在具有全国代表性的英国样本中进行倾向评分（PS）调整和PS匹配的纵向队列研究。参与者包括所有被诊断为双相情感障碍的患者，他们被处方锂、丙戊酸盐、奥氮平或喹硫平作为维持情绪稳定剂治疗。主要结局和测量主要结局是任何形式的自残。次要结局是意外伤害和自杀。结果在14396名诊断为BPD的个体中，6671人被纳入队列，其中2148人服用锂，1670人服用丙戊酸盐，1477人服用奥氮平，1376人服用喹硫平作为维持情绪稳定剂。与服用丙戊酸盐（392;95% CI, 334-460 / 10000 PYAR）、奥氮平（409;95% CI, 345-483 / 10000 PYAR）或喹硫平（582;95% CI, 489-692 / 10000 PYAR）的患者相比，服用锂盐的患者自我伤害率更低（205;95% CI， 175-241 / 10000人-年风险[PYAR]）。在PS调整后（丙戊酸盐、奥氮平或喹硫平与锂的风险比[HR]， 1.40; 95% CI, 1.12-1.74）和PS匹配（HR, 1.51; 95% CI, 1.21-1.88），这种关联仍然保持。调整PS后，与丙戊酸盐（HR, 1.32; 95% CI, 1.10-1.58）和喹硫平（HR, 1.34; 95% CI, 1.07-1.69）相比，锂的意外伤害率较低，但奥氮平没有。该队列的自杀率为每10000 PYAR 14例（95% CI, 9-21）。虽然锂治疗组的这一比率低于其他治疗组，但由于事件太少，无法进行准确的估计。结论和相关性服用锂的患者减少了自残和意外伤害的发生率。这一发现补充了有限的试验和较小的观察性研究结果。它支持了锂的使用除了稳定情绪之外还能减少冲动攻击的假设。
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.