Bipolar CHOICE (clinical health outcomes initiative in comparative effectiveness): A pragmatic 6-month trial of lithium versus quetiapine for Bipolar disorder

Andrew A. Nierenberg, Susan L. McElroy, Edward S. Friedman, Terence A. Ketter, Richard C. Shelton, Thilo Deckersbach, Melvin G. McInnis, Charles L. Bowden, Mauricio Tohen, James H. Kocsis, Joseph R. Calabrese, Gustavo Kinrys, William V. Bobo, Vivek Singh, Masoud Kamali, David Kemp, Benjamin Brody, Noreen A. Reilly-Harrington, Louisa G. Sylvia, Leah W. SheslerEmily E. Bernstein, David Schoenfeld, Dustin J. Rabideau, Andrew C. Leon, Stephen Faraone, Michael E. Thase

Research output: Contribution to journalArticlepeer-review

44 Scopus citations


Background: Bipolar disorder is among the 10 most disabling medical conditions worldwide. While lithium has been used extensively for bipolar disorder since the 1970s, second-generation antipsychotics (SGAs) have supplanted lithium since 1998. To date, no randomized comparative-effectiveness study has compared lithium and any SGA. Method: Within the duration of the study (September 2010-September 2013), participants with bipolar I or II disorder (DSM-IV-TR) were randomized for 6 months to receive lithium (n = 240) or quetiapine (n = 242). Lithium and quetiapine were combined with other medications for bipolar disorder consistent with typical clinical practice (adjunctive personalized treatment [APT], excluding any SGA for the lithium + APT group and excluding lithium or any other SGA for the quetiapine + APT group). Coprimary outcome measures included Clinical Global Impressions-Efficacy Index (CGI-EI) and necessary clinical adjustments, which measured number of changes in adjunctive personalized treatment. Secondary measures included a full range of symptoms, cardiovascular risk, functioning, quality of life, suicidal ideation and behavior, and adverse events. Results: Participants improved across all measures, and over 20% had a sustained response. Primary (CGI-EI, P =.59; necessary clinical adjustments, P =.15) and secondary outcome changes were not statistically significantly different between the 2 groups. For participants with greater manic/hypomanic symptoms, CGI-EI changes were significantly more favorable with quetiapine + APT (P =.02). Among those with anxiety, the lithium + APT group had fewer necessary clinical adjustments per month (P =.02). Lithium was better tolerated than quetiapine in terms of the burden of side effects frequency (P =.05), intensity (P =.01), and impairment (P =.01). Conclusions: Despite adequate power to detect clinically meaningful differences, we found outcomes with lithium + APT and quetiapine + APT were not significantly different across 6 months of treatment for bipolar disorder.

Original languageEnglish (US)
Pages (from-to)90-99
Number of pages10
JournalJournal of Clinical Psychiatry
Issue number1
StatePublished - Jan 2016

ASJC Scopus subject areas

  • Psychiatry and Mental health


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