How Oral Medication Can Benefit Patients With Bipolar Disorder

Although intramuscular medications such as long-acting injectables (LAIs) are becoming more and more frequently cited as ideal for patients with psychotic disorders such as bipolar disorder or schizophrenia, some experts like Leslie Citrome, MD, MPH, clinical professor at New York Medical College, are still partial to oral medication. Following his Psych Congress 2022 session "Treating Agitation: Can We Avoid Injections? Should We?” Psych Congress Network caught up with Dr Citrome to hear about when oral medication may be preferred, misconceptions, and "sandwich therapy."

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Read the Transcript:

Dr Leslie Citrome, MD, MPH: Hi, I'm Dr Leslie Citrome, clinical professor of psychiatry and behavioral sciences at New York Medical College in Valhalla, New York.

Psych Congress Network (PCN): Why is oral medication preferred over intermuscular (IM) medications? And is there an instance or a patient circumstance where the IM medication might be preferred?

Dr Citrome: Oral medications are often preferred by everyone. It's just simply easier. There's no needle involved. Patients are used to taking medicine to feel differently. When offered a medicine to help them relax, they're often accepting of it if they've had some experience with it, and they realize that this is an attempt to decrease their level of discomfort. We have to remember that agitation is egodystonic. People don't like feeling agitated, they want relief. On the other hand, they may be somewhat paranoid or suspicious. They may be thinking that you want to medicate them or sedate them. So, the idea here is to present a choice for patients. 'You seem like you're not comfortable and you seem what we call agitated, is there something that we can do to help you with that? So, tell me about that.' So, it starts a dialogue.

I also offer something like water or if I have a sandwich, we call it sandwich therapy, and it is offering something to the person to show that you care for their wellbeing. At the same time, when given a choice about what kind of medicine to receive, they're able to express a preference. You can also even say, 'We have injectable medicines that work really quickly and we have oral medicines that work a little bit more slowly, which one would you rather have?' 'Well, I don't want to take anything,' sometimes what we hear. 'Well, if you had to take something, which one would you prefer? And you know what? We have something new that you put in your mouth that is absorbed in the mouth that works just as fast as an injection. I think it's worthwhile to give it a try.'
 

PCN: What misconceptions around this topic would you like to clear up?

Dr Citrome: A common misconception is that patients will refuse medicines if they're offered them and when they're agitated—not necessarily so. Another misconception is patients don't have the capacity to provide a preference as to how they want to be treated. That's not true either. Patients are often not engaged in a dialogue as to how they're feeling and what steps can be made to make them feel more comfortable.
 

PCN: What further research do you believe is necessary in this area? Do you have any remaining questions you're planning to explore yourself?

Dr Citrome: Well, I'm really curious to see how some of the treatments we use in schizophrenia and bipolar disorder work in people with other disorders, and specifically design randomized controlled trials, for example, in people with Alzheimer disease. Would be very interesting to see if medicines can be used to help decrease agitation in that group of patients. It's a very difficult disorder to manage when patients are agitated.

Leslie Citrome, MD, MPH, is clinical professor of psychiatry and behavioral sciences at New York Medical College in Valhalla, New York, and has a private practice in Pomona, New York. He is editor in chief of Current Medical Research and Opinion, published by Taylor & Francis. He is the current president of the American Society of Clinical Psychopharmacology. Dr Citrome was the founding director of the Clinical Research and Evaluation Facility at the Nathan S. Kline Institute for Psychiatric Research in Orangeburg, New York, and after nearly 2 decades of government service as a researcher in the psychopharmacological treatment of severe mental disorders, Dr Citrome is now engaged as a consultant in clinical trial design and interpretation.