Features associated with the delayed initiation of mood stabilizers at illness onset in bipolar disorder

Background: Whether delays in the initiation of appropriate pharmacotherapy for bipolar illness negatively affect course, outcome, or lifetime suicide risk remains at issue. Method: Lifetime affective syndromes and the initial emergence of affective symptoms were assessed by lifecharting in 56 DSM-IV bipolar patients. Lifetime treatment interventions were recorded by clinical interview with corroboration via record reviews. Lag times to the initiation of a mood stabilizer (after initial symptom onset and/or first lifetime affective episode) were assessed relative to functional outcome and lifetime suicide attempts. Results: Mean +/- SD lag time from initial affective symptoms until first mood stabilizer treatment was 9.8 +/- 9.4 years. A greater number of years from symptom onset to first mood stabilizer was associated with poorer past year social functioning (r = -0.35, p = .008), more annual hospitalizations (r = 0.38, p = .004), and a greater likelihood for making a lifetime suicide attempt (odds ratio = 7.26, 95% confidence interval = 1.62 to 32.59; Wald chi(2) = 6.69, df = 1, p = .010). Delayed mood stabilizer initiation was linked with poorer outcomes in these domains regardless of initial index episode polarities of mania versus depression. Prolonged delays to bipolar diagnoses and mood stabilizer initiation were associated with earlier ages at affective symptom onset (p < .03) and milder severity of initial symptoms (p = .003). Psychotherapy initiation often preceded mood stabilizer introduction by greater than or equal to 8 years. Conclusion: Delays in the initiation of mood stabilizer pharmacotherapy at illness onset, even for relatively mild symptoms at illness onset and regardless of index episode polarity, may confer an elevated risk for suicidal behavior, poorer social adjustment, and more hospitalizations in bipolar disorder. Greater surveillance screening for bipolar illness in patients who first present for psychotherapy may help to diminish these adverse outcomes.