Pattern of Pharmacotherapy by Episode Types for Patients With Bipolar Disorders and Its Concordance With Treatment Guidelines Ji Hyun Baek, MD,*Þ Kyooseob Ha, MD, PhD,*þ Lakshimi N. Yatham, MBBS, FRCPC, MRCPsych,§ Jae Seung Chang, MD, PhD,* Tae Hyon Ha, MD, PhD,* Hong Jin Jeon, MD, PhD,Þ Kyung Sue Hong, MD, PhD,Þ Sung Man Chang, MD,|| Yong Min Ahn, MD, PhD,¶ Hyun Sang Cho, MD, PhD,# Eunsoo Moon, MD,** Boseok Cha, MD, PhD,ÞÞ Jung Eun Choi, MD,þþ Yeon Ho Joo, MD, PhD,§§ Eun Jeong Joo, MD, PhD,|||| Se Young Lee, MD,* and Yunseong Park, RN* Abstract: This study aimed to investigate the overall prescription pattern for patients with bipolar disorders in Korea and its relevance to the practice guidelines. Prescription records from all patients with bi- polar I and II disorders who have been admitted or who started the outpatient treatment during the year of 2009 in 10 academic setting hospitals were reviewed. A total of 1447 patients with bipolar I and II disorders were included in this study. Longitudinal prescription patterns of inpatients and outpatients were analyzed by episode types and com- pared with the clinical practice guideline algorithms. In all phases, polypharmacy was chosen as an initial treatment strategy (980%). The combination of mood stabilizer and atypical antipsychotics was the most favored. Antipsychotics were prescribed in more than 80% of subjects across all phases. The rate of antidepressant use ranged from 15% to 40%, and it was more frequently used in acute treatment and bipolar II subjects. The concordance rate of prescriptions for manic inpatients to the guidelines was higher and relatively more consistent (43.8%Y48.7%) compared with that for depressive inpatients (18.6%Y46.9%). Polypharmacy was the most common reason for nonconcordance. In Korean psychiatric academic setting, polypharmacy and atypical antipsychotics were prominently fa- vored in the treatment of bipolar disorder, even with the lack of evidence of its superiority. More evidence is needed to establish suitable treatment strategies. In particular, the treatment strategy for acute bipolar depression awaits more consensuses. Key Words: bipolar disorders, pharmacotherapy, prescription pattern, guideline (J Clin Psychopharmacol 2014;34: 577Y587) O wing to the complexity of the condition, treatment of bi- polar disorder continues to pose challenges for clinicians. In order to provide guidance to psychiatrists about the most appro- priate treatments for patients with bipolar disorder, various clini- cal practice guidelines have been developed. 1Y4 Although the methods vary between the guidelines, most guidelines attempt to translate evidence accumulated from clinical research studies into clinical practice with the objective to provide guidance to clini- cians in treatment decision making and thus improve quality of care and clinical outcomes for patients. It is generally believed that better guideline adherence is associated with significantly better outcomes for patients. 5 How- ever, the rates of adoption of treatment guidelines by clinicians to treat patients in ‘‘real-world’’ clinical practice are low. Recently, several studies investigating the concordance rate of clinical practice in outpatient clinic of the tertiary care hospitals, where up-to-date treatment strategy was generally adopted, with clinical guidelines reported only 20% to 30% concordance rate. 6Y8 Even within the guideline-recommended treatment, pre- ferred medications also can differ. In tertiary-care US and UK outpatient setting, lithium and valproate were almost equally preferred. 9,10 However, lithium was predominantly prescribed in Denmark, 11 whereas valproate was favored in Norway. 12 Similarly, use of antidepressant (AD), which was controversial in bipolar disorder, 13 is still prevailing in a US clinical set- ting, 7,14 yet it is less frequent in the United Kingdom. 15 Such differences in the treatment strategy might be related to ethnicity, drug approval, insurance reimbursement, and other sociocultural factors. 16,17 But previous studies had some limi- tations that undermine to generalize the results. First, most studies did not encompass manic and depressive phases. Sec- ond, except the study by Ghaemi et al, 10 there were no previous studies on prescription pattern of bipolar II disorder, which has distinct biological and clinical characteristics compared with bipolar I disorder. 18,19 As the proportion of bipolar II disorders becomes larger recently in psychiatric clinical practice and as bipolar II disorder needs different treatment strategy compared with bipolar I disorder, treatment pattern of bipolar II disorders should be separately evaluated in the real world. Third, most ORIGINAL CONTRIBUTION Journal of Clinical Psychopharmacology & Volume 34, Number 5, October 2014 www.psychopharmacology.com 577 From the *Mood Disorder Clinic and Affective Neuroscience Laboratory, Department of Psychiatry, Seoul National University Bundang Hospital, Seongnam; †Department of Psychiatry, Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul; and ‡Seoul Na- tional Hospital, Seoul, Korea; §Department of Psychiatry, University of British Columbia, Vancouver, British Columbia, Canada; ||Department of Psychiatry, Kyungpook National University School of Medicine, Daegu; ¶Department of Psychiatry and Behavioral Science, Seoul National University College of Medicine, Seoul; #Department of Psychiatry, Yonsei University College of Medicine, Seoul; **Department of Psychiatry, Pusan National University Hospital Medical Research Institute, Busan; ††Depart- ment of Psychiatry, Gyeongsang National University College of Medicine, Jinju; ‡‡Department of Psychiatry, Seoul Municipal Eunpyeong Hospital; §§Department of Psychiatry, Asan Medical Center, Ulsan University College of Medicine; and ||||Department of Neuropsychiatry, Eulji University School of Medicine, Eulji General Hospital, Seoul, South Korea. Received December 12, 2013; accepted after revision April 1, 2014. This study was supported by a grant of the Korea Healthcare Technology R & D Project, Ministry of Health & Welfare, Republic of Korea (grant A101915) and an unrestricted grant from Pfizer Korea to K.H. (Seoul National University Bundang Hospital #06-2011-011). Funding sources were not involved in study design; data collection, analysis, and interpretation of data; in the writing of the report; and in the decision to submit the article for publication. Reprints: Kyooseob Ha, MD, PhD, Mood Disorder Clinic and Affective Neuroscience Laboratory, Department of Psychiatry, Seoul National University Bundang Hospital, 166 Gumiro, Bundang-gu, Seongnam-si, Kyeonggi-do 463-707, Republic of Korea and Seoul National Hospital, 398 Neungdong-ro, Gwangjin-gu, 143-711 Seoul, Korea (e<mail: kyooha@snu.ac.kr). Copyright * 2014 by Lippincott Williams & Wilkins ISSN: 0271-0749 DOI: 10.1097/JCP.0000000000000175 Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.