Prescription Patterns for Bipolar Disorder in Asian Countries: Findings from REAP-BD
Shih-Ku Lin1,2, Shu-Yu Yang3, Seon-Cheol Park4, Ok-Jin Jang5, Xiaomin Zhu6, Yu-Tao Xiang7,8, Wen-Chen Ouyang9-11, Afzal Javed12, M. Nasar Sayeed Khan13, Sandeep Grover14, Ajit Avasthi14, Roy Abraham Kallivayalil15; Kok Yoon Chee16, Norliza Chemi17, Takahiro A. Kato18, Kohei Hayakawa18, Pornjira Pariwatcharakul19, Margarita Maramis20, Lakmi Seneviratne21, Sim Kang22, Wai Kwong Tang23, Tin Oo24, Norman Sartorius25, Chay-Hoon Tan26, Mian-Yoon Chong27, Yong Chon Park4, Naotaka Shinfuku28
1Department of Psychiatry, Taipei City Hospital and Psychiatric Center, Taipei, Taiwan
2Department of Psychiatry, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan (Dr Lin);
3Department of Pharmacy, Taipei City Hospital, Taipei, Taiwan
4Department of Neuropsychiatry, Hanyang University Guri Hospital, Guri, South Korea
5Department of Psychiatry, Bugok National Hospital, Changyeong, South Korea
6Department of Psychiatry, Suzhou Guangji Hospital, the Affiliated Guangji Hospital of Soochow University, Suzhou, China
7Beijing Anding Hospital of Capital Medical University, China
8Unit of Psychiatry, Faculty of Health Sciences, University of Macau, Macao SAR, China
9Department of Geriatric Psychiatry, Jianan Psychiatric Center, Tainan, Taiwan
10Department of Psychiatry, Kaohsiung Medical University, Kaohsiung, Taiwan
11Department of Nursing, Shu-Zen Junior College of Medicine and Management, Kaohsiung, Taiwan
12Pakistan Psychiatric Research Centre, Fountain House, Lahore, Pakistan
13Department of Psychiatry, Services Hospital, Lahore, Pakistan
14Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh, India
15Pushpagiri Institute of Medical Sciences, Tiruvalla, India
16Department of Psychiatry & Mental Health, Tunku Abdul Rahman Institute of Neurosciences, Kuala Lumpur Hospital, Kuala Lumpur, Malaysia
17Department of Psychiatry and Mental Health, Hospital Kajang, Selangor, Malaysia
18Department of Neuropsychiatry, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
19Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
20Department of Psychiatry, Dr. Soetomo Hospital - Faculty of Medicine, Airlangga University, Surabaya, Indonesia
21Department of Psychiatry, University of Sri Jayewardenepura, Sri Lanka
22Institute of Mental Health, Buangkok Green Medical Park, Singapore
23Department of Psychiatry, Chinese University of Hong Kong, Hong Kong, China
24Mental Health Hospital, Yangon University of Medicine, Yangon, Myanmar
25Association for the Improvement of Mental Health Programs, Geneva, Switzerland
26Department of Pharmacology, National University of Singapore, Singapore
27Department of Psychiatry, Kaohsiung Chang Gung Memorial Hospital and School of Medicine, Chang Gung University, Taiwan
28School of Human Sciences, Seinan Gakuin University, Fukuoka, Japan
Received: October 15, 2020; Revised: December 25, 2020; Accepted: December 26, 2020; Published online: December 26, 2020.
© The Korean College of Neuropsychopharmacology. All rights reserved.

Abstract
Objectives: Pharmacotherapy including mood stabilizers and antipsychotics are frequently used in bipolar disorder (BD); however, the lack of consensus regarding the definition of polypharmacy hinders conducting comparative studies across different settings and countries. Research on Asian Prescription Pattern (REAP) is the largest and the longest lasting international collaborative research in psychiatry in Asia. The objective of REAP BD was to investigate the prescription patterns of psychotropic medications across Asian countries.
Methods: The data collection was web-based. Prescription patterns were categorized as (1) mood stabilizer monotherapy: one mood stabilizer; (2) antipsychotic monotherapy: one antipsychotic; (3) simple polypharmacy: one mood stabilizer and one antipsychotic; and (4) complex polypharmacy: ≥2 mood stabilizers or/and antipsychotics. The psychotropic drug load in each patient was calculated using the defined daily dose method.
Results: Among 2003 patients with BD (52.1% female, 42.4 years) from 12 countries, 1619 (80.8%) patients received mood stabilizers, 1644 (82.14%) received antipsychotics, and 424 (21.2%) received antidepressants, with 14.7% mood stabilizer monotherapy, 13.4% antipsychotic monotherapy, 48.9% simple polypharmacy, 20.3% complex polypharmacy, and 2.6% other therapy. The average psychotropic drug load was 2.05 ± 1.40.
Discussions: Over 70% of psychotropic regimens involved polypharmacy, which accords with the high prevalence of polypharmacy in BD under a permissive criterion (2 or more core psychotropic drugs) worldwide. Notably, ≥80% of our sample received antipsychotics, which may indicate an increasing trend in antipsychotic use for BD treatment. A new definition of polypharmacy for bipolar disorder was proposed for easier comparison between different study sites and course phases.
Keywords: bipolar disorder, polypharmacy, psychotropic drug load, antipsychotics, mood stabilizers

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