Selecting Atypical Antipsychotics for Patients With Bipolar Disorder

Rimal Bera, MD, clinical professor of psychiatry, University of California, Irvine, breaks down major factors in selecting antipsychotics for bipolar disorder and the importance of treatments with high adherence rates.

Read the full transcript:

Welcome back to PopHealth Perspectives, a conversation with the Population Health Learning Network where we combine expert commentary and exclusive insight into key issues in population health management and more.

In this podcast, Dr Rimal Bera shares why it's important to consider adherence in patients with bipolar disorder.

My name is Rimal Bera. I'm a clinical psychiatrist and clinical professor of psychiatry at the University of California, Irvine. I've been in practice for 31 years.

My practice involves seeing patients on the chronic spectrum of illness. I treat a wide variety of different conditions as schizophrenia, bipolar disorder, and major depression. I also do some teaching to medical students, residents, family practice, internal medicine, and other primary care specialists, in helping them become more comfortable in approaching psychiatric conditions, beginning treatment, and following patients.

An estimated 45% to 61% of patients with bipolar I disorder in the United States are treated with atypical antipsychotics. So what are the major factors in selecting antipsychotics in patients with bipolar depression?

Step 1 is getting diagnostic confirmation or certainty as much as you can when you're evaluating a patient. Once we feel somewhat confident that what we're observing and the history we've gathered do appear to fit bipolar depression, you really want to get a good idea of what medicines an individual has tried before.

Just because somebody's tried a medicine before doesn't mean you may not want to reconsider it because one of the biggest challenges we have in bipolar depression is adherence to the treatment you've initiated. How long did they try it? Were they compliant to it? What were the dosages?

We now have, as you've mentioned, atypical antipsychotics that have become the forefront of our treatments for bipolar depression. They're the medications in this class that's really been well studied over the last 10 to 12 years.

Really good rigorous thorough trials have clearly demonstrated their efficacy, not just short term, but now long term. We now have a good idea of their side effect profile also, which is an important balance—not just the efficacy of the atypical antipsychotic you choose, but the adverse effect profile. A good balance is where you'd have efficacy significantly greater than effect.

And then you discuss these options with the patient. In today's treatment, it's not unusual that patients will have already done a little bit of their homework or already heard about some of the atypical antipsychotic compounds. So they may already have one in their mind that they've heard about, or maybe a family member has discussed. You want to keep that open in the sense that if they're feeling good about a medicine and you feel that's an appropriate medicine, that may be a better fit because they feel they already have a connection to that treatment.

When I approach, I'll look at what their history was. We now have 3 or 4 good compounds that are FDA approved in the atypical antipsychotic category. I will discuss adverse effects. There may be some subtle differences among the many agents and one may be more worrisome to the patient or more worrisome to myself. So this is a fairly thorough evaluation.

I think we're fortunate that we have many agents available, so we do have choices. If one doesn't seem to be a fit from the patient's perspective or my perspective, we have other good options.

Can you discuss the importance of adherence in patients with bipolar disorder?

It's probably the single most important feature to success and outcome in bipolar depression. That is adherence to the treatment that's being prescribed.

The biggest challenge we have with an illness like bipolar disorder, not just the depressed end, but even the manic end, is continued adherence to treatment. Once an individual is feeling better, not that it's common, but it's an expectation that an individual is going to maybe begin to reevaluate: “Do I still need this medicine? I'm doing well now.”

The stigma of taking a medication for a mental illness starts to creep in. So many factors begin to impact adherence and the conviction of taking this medicine. So we should expect the patient questioning the medication. If you have a treatment where data shows an individual stays on it longer, it's going to do half our job and already help us.

We're going to still have to regularly ask how the individual feels about the treatment they're on. But the last thing we want is the beginnings of nonadherence or partial compliance, independent of a discussion with the prescriber.

And the reason for that is there's a good likelihood, not necessarily in a week or a month, but maybe over 2 months or 3 months, when somebody is no longer on their medicine, we may see a reemergence of the depression of bipolar disorder. Every time you have a reemergence, it becomes more difficult to get back to that early response you had. A medicine that an individual stays on longer, and the data shows that, is huge and significant for a good outcome in an illness like bipolar depression.

Is there anything that we haven't mentioned yet that you wanted to add today?

I think this is an important condition that we are getting specific medicines for that are targeted just for the depressed piece of bipolar disorder. Rather than bipolar disorder, we're targeting specific aspects.

I do think it's important, when you're looking at a treatment and deciding on multiple options, to have the patient as engaged as possible in that decision. What are their goals? It may be, “I just want to be more engaged with my family. I want to get back to work.” Find out what they want without the assumption of just wanting their depression to lessen.

I think that leads to greater buy-in for the patient. If they have a clear target goal or target symptoms that they've conveyed that are important to them, that's going to be important for you to hear as a prescriber, so you can help them get that goal. And patients feel more heard when you're asking them, “What would you like to achieve in the treatment that we decide on?”

I think partnership and alliance is critical in a condition like bipolar depression.

Thanks for tuning in to another episode of PopHealth Perspectives. For similar content or to join our mailing list, visit populationhealthnet.com