Recalibrating a Treatment Plan for Bipolar Disorder When the Initial Therapy Doesn't Work

In Spring 2022, Psych Congress Network spoke with Mauricio Tohen, MD, DrPH, University of New Mexico School of Medicine, Albuquerque, about his session presented at the American Psychiatric Association 2022 Annual Meeting, entitled, "Bipolar Depression: Outcome and Pharmacological Treatment."

In this quick podcast excerpt taken from that conversation, Dr Tohen explains the clinical options available to healthcare professionals when initial treatment plans for patients with bipolar disorder don't go according to said plan.

To hear the full conversation and Dr Tohen's thoughts on other topics, including bipolar depression and best interventions, check out Part 1: Bipolar Depression Pharmacological Treatments and Challenges here, and Part 2: The Best Treatment for Bipolar Depression and Symptomatic Interventions here.

Mauricio Tohen, MD, DrPH, MBA is university distinguished professor and chairman of the Department of Psychiatry & Behavioural Sciences at the University of New Mexico HSC in Albuquerque New Mexico. In 2014 Dr Tohen was recognized in Thomson Reuter’s “The World’s Most Influential Scientific Minds, 2014”. He is one of 100 scientists worldwide recognized in the psychiatry/psychology category. Dr Tohen has published over 350 publications and has over 20,000 scientific citations. In 2016 the International Society for Bipolar disorders awarded him the Mogens Schou Award for Education and Teaching. In 2017 and again in 2021, Dr Tohen was Recognized by Expertscape as having the top % 0.12 expertise in bipolar disorder worldwide based on citations of published articles between 2007-2017 and 2010-2021.

Read the Transcript:

Meagan Thistle: Welcome back Psych Congress Network family! This is your Associate Digital Editor Meagan Thistle. Back in May, we had a chance to speak with Dr Maurice Tohen about the best treatment options for bipolar depression, pharmacological and neuromodulation treatments, and more. We hope that you enjoy this podcast excerpt and are excited to learn more. We will link the full podcast below in the show description if you are interested in more insights. We hope you enjoy this quick clinical pearl.

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Dr Mauricio Tohen: Thank you, Meagan. I am Dr Mauricio Tohen. I'm a distinguished professor and chairman of the Department of Psychiatry at the University of New Mexico. It is my my pleasure to be here today--thank you for inviting me. 

Thistle: Of course, thank you for taking the time to chat with us today. Let's jump right in. What advice would you have for clinicians who ask all the right questions, try out a treatment option, and it doesn't work?

Dr Tohen: Unfortunately the scenario that you present is not that unusual, and unfortunately we don't have personalized medicine where we can get a biomarker and determine what is going to be the right antidepressant or what's going to be the right treatment for this patient. We don't have that. It's going to happen in psychiatry, that we have personalized medicine. We don't have it yet. There's been some studies. So, we're still in trial and error.  And actually one of the tools that we use is what I've mentioned before fact, so-called pharmacogenetics. If there's family members with a condition, what treatments have they responded to or not, or what treatments theres’s been tolerability or not? That would be the first step.

The other thing is, don't give up too quickly. Because if you started treatment—and actually, this is part of the psychoeducation with the patient—is that if there's no response in a couple of days, the last thing you want to do is stop the treatment at that point, unless of course there are side effects, because if the duration has been long enough, in a way you've wasted that time. You want to make sure that when you rule out a specific treatment, it includes the duration of the treatment and also the dose. Dose would be key things. Stopping treatments is always a risk. So what I prefer to do, if I start treatment, do I move for something right away? Well, in some cases. But the other one, if you have a response adding a second treatment, is that reasonable? It can be reasonable, especially if there's tolerability. That of course prevents the stop of a treatment. That of course carries risk of recurrence, especially it there's abrupt discontinuation of treatment. So that's why we need to be very thoughtful on how to go about the next step. Do it slowly, if you're going to stop at treatment. Sometimes you can piggyback, as long as there's no drug interactions. Just be very careful when you're switching treatments.

Thistle: Well, thank you. I know our audience of clinicians will benefit from that advice. As we round out our time together, are there any misconceptions on any of the topics you presented that you'd like to clear up? Or any other final thoughts that you have on this topic?

Dr Tohen: Well, all the treatments that we talked about are symptomatic. We have no curative interventions in psychiatry. And many times, especially when we're talking about maintenance treatment with my patients, and that one of the first questions even with first episode is "Doc, how long will I be on my treatment?" With a first episode, you can consider discontinuation at some point because there's a few very fortunate ones that is a single episode only. But let's talk about patients who've had more than one or two episodes. The right answer to how long will I stay on my treatment is "As long as it helps you and you tolerate it, you'll stay on the treatment until we find a cure." And I'm hopeful that within our generation, we will find better treatments than we have now. We're doing better than in the past, but we certainly have a long way to go.