Transcript: Clinical Tips for Prescribing Medications for Bipolar Disorder

Below is the transcript for Clinical Tips for Prescribing Medications for Bipolar Disorder

Erin Walcykowski:
For clinicians prescribing medications to patients with bipolar disorder for the first time, this is some of the key advice that I would provide to you.
Have a strategy. As clinicians, we've gone through years of schooling, we have a foundation. We know what medications potentially work best in mania, what medications potentially work best in depression.

We tend to make our treatment decisions or preferably make our treatment decisions based on research, based on data, based on information that can support why we are making the choices we're making versus just using anecdotal data. So, you have a starting point. That's what I like to say. We're not going into this blind. If you're not as familiar with bipolar disorder, you're not used to treating it, you just know that you're going to be prepared to develop a strategy and the strategy's going to have to be individualized because every patient does not present the same.

They don't exhibit all the symptoms of bipolar disorder and it could be a different variety of combinations depending on the individual. Depending on the individual and depending on their family, because some people, their family looks different. Some people have the most supportive family. Some people have maybe a more challenging dynamic already within the family. Some people don't really have a support system at all.
Trying to keep that in mind as well as you're developing a plan, these factors are important.

One of the things you want to be mindful of is how quickly can you make med adjustments? How safely can you make these med adjustments? And it depends on whether they're in a depressive episode or whether they're in a manic episode, but of course, you're wanting to address this as quickly as possible, but as safely as possible.

As a clinician, depending on your setting, inpatient versus outpatient, private practice versus an ACT team or community mental health, it's going to vary, because that really speaks to whether you have a team.

How many people are actually providing care to this individual, to this patient, to their family? Can they come in pretty regularly if you need them to? Do I need them to come in on a weekly basis? Do I feel like the med adjustments or the dose increases, or if I have to add on something, how likely are they to adhere to this? How are they tolerating these increases? How quickly is it working? Their symptoms, are they getting worse? Am I starting to be concerned for their safety in any way?

Those are some things you want to think about.

If you feel that the med adjustments that need to be made are more aggressive than you're comfortable with, particularly in an outpatient setting, then you have to make the decision whether it's best to have them go to an inpatient setting.

Ideally, you always want them to be on board and be able to make the decision for themselves and agree to the treatment plan. Whatever adjustments are happening along the way, so that's important.

You also want to be mindful of, again, when you're deciding: can I treat them on an outpatient basis? Let's say versus an inpatient basis, observation, keeping an eye on them. 

Are they doing anything that's so impulsive, that's so out there that it's going to cause irreversible social or economic harm? So some serious financial damage. Are they going to be doing things that put them at risk for being arrested? All the way to are they at risk for harm, direct harm to self or others? Do they need to be involuntarily committed versus voluntary?

The goal is always to get them like I said before, to buy into the treatment plan, to get them to accept whether it's the patient or the family that, "Hey, this individual would receive the best treatment at this point by going inpatient versus managing this outpatient." Going over that criteria. 
What criteria is there to determine whether this person needs to be hospitalized? What's the threshold? Have they met it? Are they getting close?

Something else to consider in terms of the medication side is pregnancy status in women of childbearing age.  Are they pregnant or are you able to do some testing beforehand?

Sometimes, they don't have the level of organization that's required for them to go get tested. Something I like to do is just keep home pregnancy test kits on hand in the office, in case you need to rule out something very quickly, because typically depending on whether they're depressed or manic and you need to get that treatment started right away, you may not have the luxury of having a bunch of lab results or having certain data on hand.

You need to decide. Another good tidbit to keep in mind is: you're trying to get their symptoms under control as quickly as possible.
Most importantly, be prepared to start meds. I know sometimes when we see patients depending on their diagnosis, depending on their symptoms, it's good to take some time to go over the data, go over the information you're getting from the patient, do some research, consult with some colleagues and then make a decision.

But depending on the symptoms, depending on their presentation, depending again whether they're depressed or manic, are they suicidal? Are there serious concerns here? You want to be prepared to start medications.

I think the most ideal start would then be to consider typically your antipsychotics, second generation antipsychotics, because you want quick efficacy, so those are good places to start.

Be mindful, keep an eye out for any side effects, keep an eye out for efficacy, how quickly that's kicking in. Other considerations, again, the limitations of outpatient. As clinicians, I think we want to help our patients as best we can. We want to see them improve.

Even in terms of your treatment plan, your ideas, you know, “okay, if I can get this person to start this medication or start these 1 or 2 medications, this would likely help them pretty quickly.”

Essentially, you don't have eyes on 24/7, you cannot force them to take the medication. You strongly encourage them to. Of course, you get the family on board to see if they can assist with getting the patient to adhere to the treatment plan but ultimately, that may not go the way you want. Knowing that, “hey, we've done everything we could on our end. So now maybe we need to bump them to a higher level of care.”So, always keep that in mind as well. 

Substance use, that's a big one. Have they used any substances recently that could be impacting the clinical picture, their substances that they need to stop? How easy is that to facilitate? How receptive are they to that? That could be street drugs, or it could just be something like coffee or energy drinks, making sure they're not either using it or will not continue to use it to help get their symptoms under control.

What medications are already on board, you want to think about that. What's their current regimen, if they're already currently prescribed medications? And you made the decision, "Hey, I think this is Bipolar disorder." Are they on an SSRI or antidepressant and that caused some activation? Do I need to pull that off? Are they on a regimen already that maybe already supports the symptoms of Bipolar disorder, but maybe they just need a dose increase, or maybe they just need adjunct?

Simple is best. I'm a big fan of that, particularly if someone is struggling with mental health symptoms, you have a lot of players on board trying to make this work, to provide the best care, simple is typically best. You don't want to make the regimen too complicated for the patient to adhere to. If possible, you don't want to make it too complicated in terms of the number of times a day. Obviously, once a day is better than twice a day.

You do what is necessary based on their symptom, based on their presentation, based on what will help them, but try to keep it as simplified as possible. That's ideal. Also keep in mind PRNs. I think PRNs are very important because they might need some help while you're waiting for some of these other meds to do their job. 

You want to have the family in on this as well, because while yes, I've seen some patients that are able to recognize when they need to take a PRN, when that would be helpful, sometimes they can't and won't.

Their family might need to step in and be able to identify and recognize, “okay, this person needs to take a PRN to help when they're too symptomatic throughout the day,” knowing when's appropriate, how much is appropriate so that they don't give too much. That's important, just to give them some relief in the interim, while you're waiting to see what regimen will really help them.

So, how can patients and families be educated on the importance of adherence?

I'm a fan of starting with a conversation. Again, goes back to that education piece. Do they understand what Bipolar disorder is? What it looks like, what's causing it? The fluctuations, the imbalance in brain chemistry, so just having resources on board, again, whether that's printouts, documents, other team members that can be on board to help explain things for them.

I like visuals, whether that's a chart, that's something that they can actually look at and reference. Again, support groups. I think reinforcing the information is important, having an open environment so that they can ask questions and feel comfortable asking questions about what it is that they're experiencing, what they're seeing from a patient perspective or from a family perspective, what they're observing with their loved ones, and just having that open dialogue to make sure they're clear on what is happening with their treatment.

That’s very important technology, depending on their access to technology, depending on their level of insight, awareness, websites, things that just I think keep things simple. That's the goal, keep things as simple as possible, simple and easy to remember. I always say I like to explain things to my patients and their family as if they were five years old. So being mindful that not everyone is going to have the same level of understanding, same education level. So you want to just keep it to where it's easy to understand, because the easier it is to understand, I feel like the easier it is to retain, the easier it is to I think tap into this information, particularly when things are running high.

When the patient is in distress, when the family is in distress, and they're frustrated, and we know that can kick in some anxiety and make it difficult to focus and concentrate and remember things. So you just want to be mindful of any language barriers, any cultural differences. You just want to be sure that you're providing as much information that they can understand as possible. So if there's a language barrier, you want to make sure that you're using a language line, or connect them with individuals that can help them, that can speak their same language, or are they going to an agency or a center or a program that understands the complexities or the nuances of a particular culture or language. I think that's really important.