Clinical Considerations for Treating Patients With Bipolar Disorder

Rimal Bera, MD, clinical professor of psychiatry, University of California, Irvine, shares clinical considerations that guide treatment choices for patients with bipolar disorder, as well as unique challenges this patient population faces when seeking care.

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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.

On today's episode, Dr Rimal Bera shares what payers should keep in mind about patients with bipolar disorder.

My name is Dr Rimal Bera. I'm a clinical professor of psychiatry at the University of California, Irvine. I've been full-time faculty for the last 31 years here at the university with multiple different responsibilities, including research, development of new compounds, and ideas to treat mental illness.

I do a lot of teaching and clinical care. I've also had an interest in the last 9 to 10 years in health care policy, being involved in designing new ideas for delivery of care that are more efficient, comprehensive, and cost-effective.

How do you select treatment options for patients with bipolar depression, and what matters most to patients and their families?

First and foremost, bipolar depression is not an easy diagnosis. It does take some skill to have confidence that the depression you're seeing is depression of bipolar disorder vs depression of unipolar, or pure major depression.

My approach is to try to get a complete diagnostic history of their mental illness, and that's going back as far as one can. It's very important, I think, when assessing bipolar depression, to have a collateral informant—a family member, a friend, somebody else that knows them. It's often challenging for somebody in the middle of a depression to have the recollection of their history, so that's a very important piece.

Spend time on getting as thorough information as you can. There's a good likelihood this individual's been in that low mood for some time. So rather than being rushed with “I've got to have a diagnostic certainty and start a treatment right at this moment,” I think it's worthwhile to spend some time, maybe a second or third appointment, giving some homework to the patient and their family.

That is the first point: trying to get some diagnostic confidence. ‘Certainty’ is a strong word in mental illness, but ‘confidence’ is a very appropriate word with what you're observing and seeing.

Second, there’s a good likelihood that many individuals you're seeing that you feel do have a bipolar depression diagnosis have been on other medications and treatments. That’s an extremely important second point.

I found in my 30 years of clinical experience, I don't always want to rush that in the first visit. In other words, "Tell me the medicines you've been on. When did you take it? How long did you take it?"

That takes some time, and that's a great homework assignment for individuals after the first appointment or two. Go home. Talk with your family, your parents, your siblings, your spouse, other people who know you, to get as detailed a medication history as you are able to provide, because that will give me a good idea what to do at this next step, based on what you've tried.

You'll find something in their history—either they didn't take it long enough, the dosage wasn't complete—that you can revisit, because very often in a patient's or family's mind, if something has been prescribed and they're not on it any longer, they immediately cross it out. We don't want to lose a potential good treatment just because there wasn't a good trial of that medicine.

Then I look at what goals that patient has. What's disturbing them with regard to that low mood? Are they not able to fulfill their home responsibilities, work responsibilities, or other responsibilities in their life? Rather than just, I want to improve your mood. How is that low mood impacting their quality of life?

I think that's important to establish early, so we're all on the same wavelength of what we want to achieve. With whatever treatment I introduce, we can use those as 2 benchmarks or goal signals. I want to make sure I understand what that individual wants, maybe what their family feels is a good goal.

For bipolar depression, more and more treatments are coming forward, and all very good treatments. They've been well studied, and it's been clinically established they are beneficial in bipolar depression.

So once I've established a history of treatments they've tried, and if I feel confident those treatments had appropriate, adequate trials, I will take a look at some medications that they've not taken. I will also look beyond just the depression. Maybe the individual has had some adverse effects to previous agents. Some of our newer treatments may have certain increased risk of adverse effects that I may not want to introduce to that individual. That may gravitate me toward one group of compounds vs this other group of compounds.

For instance, some agents may help with sleep a little bit more, which might be something I'd like to achieve for an individual who also has some sleep disturbance. Beyond just the pure help with depression, what are some secondary or tertiary benefits that this compound may have for this specific individual?

And I'll certainly discuss those choices with the patient and their family. What happens more times than not, they'll leave it up to me as the clinician. “We trust you, what do you think's the best fit?” And I'll often choose one of those compounds and say, "I think this will have good efficacy for this reason, and from an adverse effect profile, I don't think I have a high worry that you may experience this."

And what should payers understand about the burdens of this patient population to better inform formulary decision making?

I almost consider this process as one of the big barriers that we have today, once myself, the patient, and the family have decided on an appropriate treatment. If we've come up with a compound that is a very good fit, that's far from assuring this compound is guaranteed to be utilized, even though I've written a prescription after a thorough, complete assessment.

It appears it's becoming more common than uncommon that I will write a prescription, the patient will go to the pharmacy, and it'll be kicked back to me saying, no, we want them to start drug A or B and fail that first before they can get the drug I'm considering is the best fit. So that's a real challenge.

Another barrier, once that medication has been approved, is prior authorization. It almost seems that even with drugs approved at the beginning, 3-6 months down the line, some decision is made that the patient can't be on that drug any longer. We have to go through this process of approving the medication again and justifying why should they stay on that medicine.

I think you can appreciate these are mental illnesses. The rapport and comfort of an individual agreeing to take the medication has really taken a lot of sophistication, and there's a real art to it. And if that gets disturbed—when an individual goes to the pharmacy after taking a medicine for a few weeks or a month, and the drug is no longer covered—it just shatters that therapeutic alliance. With somebody already somewhat uncertain about wanting to take this medication for whatever reason, you can really set back a patient who was on the road to really getting well.

Thank you, Dr Bera. Is there anything else you'd like to add today?

It's an exciting time right now in our approach to bipolar depression. We are becoming more clinically sophisticated, not just as psychiatrists, but as an entire mental health treatment community.

We are, I think, asking the right questions to tease out whether it is pure depression or bipolar depression, because there are very different treatment approaches. It's very important that we can discriminate what type of depression it is because outcome's going to be very different.

We're no longer satisfied with the status quo. We must challenge ourselves periodically in our evaluations of patients. Can we do better? Can we improve the bar of outcome? Get that person back to work, get them involved and connected to their family again, not just, oh, they're no longer suicidal. That's not adequate any longer.

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