Using Maintenance Care to Break Through the Complexities of Treating Bipolar Disorder 

Helping patients with bipolar disorder achieve a stable state can be complex, according to Christoph Correll, MD, professor of psychiatry at Hofstra Northwell School of Medicine and medical director of the Recognition and Prevention program at the Zucker Hillside Hospital. Since multiple comorbidities are common and finding a balance between depression and mania can be intricate, what can clinicians do to ensure that patients with bipolar disorder are getting optimal treatment? The key, Dr Correll emphasizes, is maintenance care.

Dr Correll presented at Psych Congress 2022 on "Long-Acting Injectable Antipsychotics: Newer Strategies for the Optimal Management of Bipolar I Disorder." Be sure to reserve your spot now for Psych Congress 2023 and join us in Nashville, Tennessee, next September! For more news and insights from this year's conference, visit the newsroom.

Christoph Correll, MD, is a professor of psychiatry at Hofstra Northwell School of Medicine, New York, and medical director of the Recognition and Prevention program at the Zucker Hillside Hospital, New York. Dr Correll completed his medical studies at both the Free University of Berlin in Germany and at the Dundee University Medical School in Scotland. Dr Correll is board-certified in general psychiatry having completed both residencies at The Zucker Hillside Hospital in New York City.

Dr Correll’s research and clinical work focus on the identification, characterization, and psychopharmacological management of adults with severe psychiatric disorders. His areas of expertise range from the prodrome and first episode to the refractory illness phase of patients with severe mood and psychotic disorders. His research further focuses on psychotropic medication efficacy, effectiveness, and adverse effects as well as on physical health in the mentally ill.

Read the Transcript: 

Bipolar disorder arguably is 1 of the most difficult to treat disorders in psychiatry. Actually, when you can manage bipolar disorder well, you may have touched almost everything you need to know. Why? Why is it so complex? Well, first of all, you have to treat 2 poles. You want to treat depression, but it's not depression alone. If you get them too high, they can get manic.

And there is even something that's called mixed mania or mania with mixed features, where you have both. So how do you treat this from above and from below? What is an ideal bimodal mood stabilizer? How many medications do you need to get stability? Which patient has a polarity index that they get more mania or more depression? Although we know that overall depression is the more prevalent component of bipolar disorder so that makes it already complicated. But patients with bipolar disorder, on average, have 3 to 4 medications on board.

Why is that? Because they also have a very high number of comorbidities. Anxiety disorders, very common, post-traumatic stress disorder, obsessive-compulsive disorder, substance use disorders—very, very common and you need to manage all of those. But if you treat anxiety, if you treat obsessive-compulsive disorder, again you might kick people into mania.

So it's quite complex to get patients into a stable state. And we know if there are residual symptoms, the risk of relapse is very common. And that brings us to maintenance care. Getting them well acutely is 1 thing but then you need to prevent relapses. But prevent relapses either into mania and/or into depression. And here again, our medications have different strengths. Antipsychotics as mood stabilizers [are] generally better from above and treat mania. Lithium too. From below, we have lamotrigine, not much else. Although now some antipsychotics also are proof for bipolar depression.

So that's again something that might come into the mix. And then patients with bipolar disorder are often higher functioning than patients with schizophrenia. So for them, it's not as easy or even harder to tolerate, weight gain and obesity, sedation, cognitive dulling, sexual side effects. So we need to really select medications well, so that they don't feel, "I'm fine now." It's an episodic illness. They might have euthymic interim periods: they stop everything and boom, the next episode happens. That's a real problem.

So here, long-acting injectables are also a possibility to keep at least 1 medication as a safety belt in the system, so that when substance abuse happens or patients are wavering with taking other medications, you at least have something in the system that will hopefully attenuate any worsening, and you can get patients back into treatment earlier.