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Optimizing Response to Bipolar Disorder Treatment

September 13, 2020

(Part 2 of 5)

In this video, Joseph F. Goldberg, MD, details factors that could influence a patient's response to a treatment for bipolar disorder, and how clinicians can address them. Dr. Goldberg, Clinical Professor of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York, gave a presentation at Psych Congress 2020 titled "Tailoring Individualized Pharmacotherapy for Bipolar Disorder: How to Translate Findings from Clinical Trials to a Single Patient."

Read the transcript:

Now let's imagine you've identified what are appropriate treatments that could do a very nice job in treating any phase of illness, mania, depression, relapse prevention. Let's say that that's an efficacious treatment. I know that lithium or aripiprazole or olanzapine or you choose, this is an appropriate drug.

Now, I want to get a better sense as to what might interfere with an optimal response. I can have the best treatment in the world, but if it doesn't come off the way I'd hope, I run the risk of disrupting a potential outcome.

What can derail a good outcome? Nonadherence, side effects, new comorbidities that come up. That could include substance use disorders. That could include psychiatric comorbidities. That could include medical comorbidities. Cost factors. Loss of insight. "I feel well now. I don't need medicine anymore, so I'm going to stop the medicine." The quality of the therapeutic alliance. "Nice to have met you, doctor, but I don't think I want to continue working with you. In fact, I'm not even sure I want to continue." These are all some of the things that could potentially interfere.

How do you anticipate those things? As a clinician, you certainly want to have them in your own mind. You may want to share them in a very tailored way with the patient. For example, someone who presents having had many side effects with medicines in the past.

You might want to take that at the very front end and say, "Look, anything that we choose to treat you can have side effects. Even placebos can have side effects. Everything's a risk‑benefit analysis. Let's talk about what kinds of side effects have come up for you in the past. Let's talk about whether or not they become deal‑breakers for you."

Some patients might say, "Certain side effects, uh‑uh. Weight gain, no can do. Sedation, no can do. Headache/nausea, maybe." Things that are transient, things that are dose‑related. Akathisia, for instance, is a dose‑related side effect.

Side effects that tend to come later versus earlier. Movement disorders like tardive dyskinesia are late side effects. Weight gain, with certain medicines in the bipolar world, are later side effects.

I will usually tell patients I want to be very attentive to side effects. I want to first do no harm, but I also want to choose medicines that are going to be right for you. Here's our contract. Here's our deal. I will be hovering and looking for any kinds of side effects that come up. I'll ask you about them.

If you happen to read about side effects on the Internet, I'd ask you just to let me know what you read so that I can at least have a chance to vet the information that you've come across and give you some context for it. My job is to be vigilant, like a spotter at the gym making sure that you're safe with this medicine. Let side effects not be a deal‑breaker.

If there comes a point where you decide you really don't like this medicine, I'd ask—this ties in with therapeutic alliance too—let me know. Loop me in. I'm not here to be judgy. I'm here to try to be helpful. If there's something that's not to your liking, let me try to help.

Maybe it's the frequency of dosing. Maybe it's cost. Maybe it's a side effect we didn't touch on before.

I'll normalize the experience for the patient and say many people have the experience of missing doses. Or they feel better, and they want to stop. I would only ask if that were to happen for you, let me know sooner than later. Maybe I can help.

Those are some of the ways in which we can try to anticipate some of the possible things that could derail a successful outcome. Hopefully, with good anticipation, we can optimize the results.

More with Dr. Goldberg: Clinical Characteristics Affecting Response to Bipolar Disorder Treatment

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