Persistence of Lithium Underutilization in Patients of African Ancestry with Bipolar Disorder

Bipolar disorder is a chronic disease that imposes a lifelong burden on those that suffer from it. Lithium is still considered both gold standard treatment and first-line maintenance treatment, and access to treatment with lithium is paramount to improving patient outcomes. However, access to adequate treatment is not only contingent on symptom recognition, accurate diagnosis, and individualization of treatment, but also affected by racial and ethnic disparities at each stage of patient experience. Individuals of African Ancestry with bipolar disorder are more frequently misdiagnosed with non-affective psychoses, less likely to receive minimally adequate treatment or be prescribed lithium, and more likely to be prescribed antipsychotics. To compare prescription patterns in the treatment of bipolar disorder between individuals of African and European Ancestry, we conducted a pooled meta-analysis of four cohorts spanning different clinical settings, recruitment periods, and ascertainment methods, followed by sex-stratified analyses. We found that, overall, individuals of African Ancestry with bipolar disorder were significantly less likely to be prescribed lithium, and more likely to be prescribed first and second-generation antipsychotics during their lifetime, than those of European Ancestry. Furthermore, both men and women of African Ancestry were independently less likely to be prescribed lithium and more likely to be prescribed second generation antipsychotics than men and women of European Ancestry. However, women appeared to be more burdened by the significantly increased likelihood of first-generation antipsychotic prescription than men, for whom the association was marginally non-significant. This continued underutilization of lithium likely stems from the complex interaction of multiple biases.