Using Moderators and Mediators to Tailor Bipolar Disorder Treatment

(Part 1 of 4)

In this video, Joseph F. Goldberg, MD, explain why is it important for clinicians treating bipolar disorder to consider both moderators and mediators of treatment outcomes. He also discusses the concept in his session titled "Bespoke Psychopharmacology: Tailoring Individualized Pharmacotherapy for Patients with Bipolar Disorder" being presented at the 2021 Psych Congress Regionals meeting series, which continues March 19 and 20.

Dr. Goldberg, Clinical Professor of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York, is a Bipolar Disorders Section Editor for the Psychiatry and Behavioral Health Learning Network.

Read the transcript: 

This concept of moderators and mediators means what factors and characteristics about a particular given patient might be associated with a uniquely beneficial outcome. Those are things like baseline severity, number of episodes, age at onset, family history, certain comorbidities. 

When you think about bipolar disorder, it's more than just the diagnosis, per se. It's really all these other characteristics that define the individual with bipolar disorder and should really help to tailor the approach to their treatment.

Someone who's in their first episode versus their umpteenth, someone who has a pure mania, versus a mixed-episodes presentation, somebody with rapid cycling, versus not-rapid cycling, someone with psychosis or not psychosis, or anxiety or no anxiety, or an eating disorder.

You get the picture. There's lots and lots of characteristics that really help us pin down what some might call a deeper phenotype of the patient.

We've learned certain medicines work better for certain kinds of patients. Lithium, for instance, tends to work better in a pure euphoric, early-episode patient with a family history. Divalproex and carbamazepine may be a little more robust in multiepisode patients or those with mixed features, or possibly with certain forms of substance use. Certain second-generation antipsychotics have been shown to have value for both depression and anxiety.

So, my thinking of moderators and mediators is not just to make the diagnosis, but to really paint a portrait in my own mind of all the characteristics that are relevant to outcome, as best one can, for a given patient. And then really try to broker a match or the best fit between their given clinical profile and the best-fitting option for their presentation.