Finland, 18,018 people with bipolar disorder: lithium tied to the fewest rehospitalizations, quetiapine to little
"9721 patients (54.0%) had at least 1 psychiatric rehospitalization." Lithium: hazard ratio 0.67. The most used drug, quetiapine: 0.92.
Reasonable evidence with real limitations. how we score evidence
Caveat on this rating: Observational; the cohort is people already hospitalized once, so it says little about milder bipolar illness. The gabapentin result is unexpected and did not survive the sensitivity analyses.
Bipolar disorder is treated for life, and the most prescribed drug for it is not the oldest or the cheapest. This study asked which drugs kept people out of hospital.
Significant findings
Lahteenvuo and colleagues (JAMA Psychiatry, 2018) followed "all patients in Finland who had been hospitalized for bipolar disorder (N = 18 018; mean follow-up time, 7.2 years)", each person as their own control. "9721 patients (54.0%) had at least 1 psychiatric rehospitalization."
The lowest risks of psychiatric rehospitalization were with "risperidone long-acting injection (HR, 0.58", "gabapentin (HR, 0.58", "perphenazine long-acting injection (HR, 0.60" and "lithium carbonate (HR, 0.67 [95% CI, 0.60-0.73])". For admission for any cause, including physical illness, "lithium (HR, 0.71 [95% CI, 0.66-0.76]) was associated with the lowest risk."
"The most frequently used antipsychotic treatment, quetiapine fumarate, showed only modest effectiveness (risk of psychiatric rehospitalization: HR, 0.92 [95% CI, 0.85-0.98]".
The authors' conclusion: "Lithium was the most effective mood stabilizer, and long-acting injections the most effective antipsychotics, in preventing hospitalization due to mental or physical illness." Only those two findings held up in every sensitivity analysis.
Worth asking
The drug with the best record here is a generic salt that nobody markets. The drug with the weakest record is the one most often prescribed. That gap is the marketing story in this library seen from the outcomes side. The conflict statement lists industry grants and advisory roles for several authors; lithium, the winner, has no sponsor. Lithium needs blood tests and has real kidney and thyroid risks, which belong in the same conversation. Never stop a mood stabilizer on your own.
Source
Real-world Effectiveness of Pharmacologic Treatments for the Prevention of Rehospitalization in a Finnish Nationwide Cohort of Patients With Bipolar Disorder — Lahteenvuo M, Tanskanen A, Taipale H, Hoti F, Vattulainen P, Vieta E, Tiihonen J (2018)
Top-tier peer-reviewed journal
Read the source: https://doi.org/10.1001/jamapsychiatry.2017.4711
DOI: 10.1001/jamapsychiatry.2017.4711
How this was scored
- Study design
- Cohort study
- Funding
- Funding not disclosed
- Published in
- Top-tier peer-reviewed journal
- Sample size
- 18,018
- Preregistered
- not recorded
- Conflicts disclosed
- Yes
- Independent of proponent
- not recorded
- Retracted
- No
Read the full scoring rubric, including what it can't tell you.
Published September 21, 2026.
Questions
How strong is the evidence behind this?
veisund rates this source "moderate evidence". Reasonable evidence with real limitations. It scores 62 out of 100 on our published rubric. One caveat travels with that badge: Observational; the cohort is people already hospitalized once, so it says little about milder bipolar illness. The gabapentin result is unexpected and did not survive the sensitivity analyses. The score is calculated from recorded facts about the source — study design, funding, publication venue, sample size, preregistration — not typed in by an editor.
What is the source for this?
Real-world Effectiveness of Pharmacologic Treatments for the Prevention of Rehospitalization in a Finnish Nationwide Cohort of Patients With Bipolar Disorder — Lahteenvuo M, Tanskanen A, Taipale H, Hoti F, Vattulainen P, Vieta E, Tiihonen J (2018). Published in: Top-tier peer-reviewed journal. DOI: 10.1001/jamapsychiatry.2017.4711. The full source is linked on this page so you can read it yourself.
Who paid for this research, and does that matter?
Study design: Cohort study. Funding: Funding not disclosed. Independence from the proponent is not recorded. Industry sponsorship is one of the most reliably measured biases in medicine, which is why funding carries real weight in the score rather than sitting in a footnote.
Is this medical advice?
This is information to bring to your prescriber, not medical advice and not a reason to change anything on your own. Nothing here is an instruction to stop or reduce a medication. If you are in crisis, call or text 988.
This is information to bring to your prescriber, not medical advice and not a reason to change anything on your own. Nothing here is an instruction to stop or reduce a medication. If you are in crisis, call or text 988.