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Dr. Roger McIntyre Gives a ‘Call to Action’ and the Latest in Bipolar Disorder Management
In this podcast, Roger McIntyre, MD, FRCPC, Professor of Psychiatry and Pharmacology, University of Toronto, Ontario, Canada, discusses his seminar that was written as a "state of the union" address regarding the current state of bipolar disorder (BD) treatment and where it is going in the future. Recently published online in The Lancet, the seminar dives deep into the reasons for the high mortality rate among patients with BD, disease misdiagnosis, and treatments both new and old. Here, Dr. McIntyre addresses these topics and how his seminar relates to current clinical practice.
Read the transcript:
I'm Roger McIntyre, professor of psychiatry and pharmacology at the University of Toronto. The paper I'll be speaking to is a paper entitled "Bipolar Disorders." It was a seminar published very recently in The Lancet.
Inspiration for the Paper (00:12)
There were 3 factors that provided the impetus for myself and my colleagues to prepare and publish this recent article in The Lancet, covering what I would call a state of the union address on bipolar disorder.
The first was recognition that most adults who have bipolar disorder are not diagnosed. They, in fact, live their life without even knowing they have bipolar. If they are diagnosed, they often wait 5, 10, sometimes as long as 15 years from the time symptoms first manifest themselves to the establishment by their care provider of the diagnosis of bipolar.
In this delay and this misdiagnosis, I'll even say pandemic, if I could, has been going on far too long, contributing to the woeful outcomes that most people have with bipolar.
Second, the impetus is that there's now recognition that amongst people with serious mental illness, which includes but is not limited to bipolar disorder, the mortality rate is higher than the general population. In fact, in bipolar disorder, the population together loses about 10 to 20 years of life when compared to the general population. That's largely because of modifiable factors like cardiovascular disease.
Third and finally, the last two decades we've seen more treatments for bipolar either regulatorily approved or proven effective than we've had in the last seven decades combined. There's been a bit of a bonanza of new treatments, not just medicines, but also evidence-based psychosocial treatments, psychotherapy, peer support, and so-called neurostimulation.
Taken together, the time was right. How do we do better for screening, do better to reduce the morbidity and mortality, and get people on the right treatments?
Research Method and Significant Findings (1:57)
The research method was, in many ways, iterative. What I did was is I reached out to colleagues around the world, who were colleagues who have submitted and have led their own intellectual research in this area. In other words, novel, innovative thinkers.
I wanted them to put on not just their ability to curate the literature and know how to synthesize it, that's important, but also put on those futuristic goggles, "Where are we going?" The people that I identified were, in fact, meeting that bill and exceeding it.
What I took away, especially, was frankly the staggering rate of cognitive impairment in people who have bipolar. In other words, most people with bipolar are significantly cognitively impaired, contributing to impaired role function, loss of human capital, can't perform at work. It's staggering, almost in some cases as bad as we see in schizophrenia.
The second of two real calls to action is the perniciousness, the hazards posed by depression. Bipolar is defined by mania, but depression clearly is what predispose and portends the tremendous functional impairment, and in many cases, the mortality through functional impairment in this illness.
Another takeaway I had, which is, in many ways, going back to the future, was at lithium, which we identified back in 1817. This salt called lithium still remains the gold-standard, mood-stabilizing drug. Not for everybody, but for a significant percentage, maybe 10 to 20 percent of people seen in clinical practice.
One other final takeaway, I think, so relevant to clinicians is we now have an assortment, a surfeit, in fact, of treatments for not just mania but the most common presentation being depression.
We now have some viable, safe, effective treatments in depression cutting across different types of drugs, anticonvulsant drugs, atypical antipsychotic drugs. Here's the part most controversial, some antidepressants actually work and are safe in bipolar depression. That's a very radioactive topic in the field, the role of antidepressants in bipolar.
A bit of these, very practical takeaways and then one final futuristic. Looking to those goggles of the future, we wondered about pluripotent stem cells, receiving a lot of interesting stem cell research. We're using it as a paradigm, as a model to begin to understand the lesion of bipolar, the molecular lesion, and also serving as an assay to test new drugs for bipolar.
Practical Implications for Clinicians Treating BD (4:58)
There are several practical implications that our paper underscores. First, every time a clinician sees a depressed patient at initial consultation or at subsequent visits, if the patient is not doing well especially, that patient should be screened. Don't be afraid to screen your patient many times for bipolar disorder. Often, it doesn't declare itself for many years after the depression. Screen and screen and screen for bipolar.
The second very clear takeaway is you need to manage above the neck and below the neck. What I mean by that is we have got to, in fact, contemporaneously manage the cardiovascular health, obesity, type 2 diabetes. These are the most common comorbidities in bipolar, and they predispose death due to cardiovascular disease.
Moreover, we now know, and we put this in the paper, that obesity metastasizes to your brain, that's a metaphor, reducing cognition, increase in the risk for depression, also, in fact, likely diminishing psychotropic drug activity. We've got to manage patients holistically.
The other takeaway message is that we know that there's an implementation gap. We put this right in the paper. What is an implementation gap? It's a gap between what we should be doing based on the best available science and evidence and what's actually happening.
Although, we all look for the new treatment for bipolar, let's just use the current tools properly. Let's narrow the gap. This is, in fact, capable by using evidence-based medicine, using measurement of patient symptom outcomes, using clinical practice guidelines to select and sequence treatments algorithmically.
Taken together, doing all of that will, in many cases, be enough to take a patient off trajectory, putting them back onto a normal trajectory of life.
Changes or Awareness Brought on by This Paper (6:46)
My hope is that the human capital loss, the debasing of human capital that is staggering in bipolar at the individual level, at the societal level, is, in many cases, modifiable in the sense that too often patients are not diagnosed or not diagnosed timely.
This implementation gap, this gap between what we should be doing and what we're actually doing, has got to narrow, because it is unacceptable. I find it, in many ways, a scenario that we can no longer tolerate, where we have a group of people with a medical illness who are dying at a much earlier time in life, 10 to 20 years earlier, by modifiable factors.
Just like cancer, diabetes, heart disease, arthritis—I can keep going—we need to have, in fact, intensity and an attention to the quality of care for these people that they deserve, so that we can, again, get them back on the trajectory that they deserve to be on.
We can't cure everything with bipolar disorder. It is a fact that the great majority of people with bipolar can be doing a lot better with respect to getting back to work, having positive mental health, general well-being improvement if we can just close that implementation gap. For me, that is the call to action.
The second, in the academic space, where I spend a lot of my time in terms of research, treatment, discovery, and development, we now have new paradigms that we can look at to think about not just a new treatment for bipolar, but what we really need.
Treatments that get people better in one day, treatments that actually cure the illness, treatments that treat suicidality, treatments that get people back to their usual role function—this is called PROs, patient-reported outcome research. That's the future, using the best technology to deliver on what patients want, patient-reported outcomes. That's what we're doing in bipolar, and we covered this in the paper.
Final Thoughts (8:48)
My final thoughts are to all clinicians. Let's, in fact, be contemplative, move from precontemplation to contemplation on bipolarity as a possibility. Secondly, screen for bipolar, use the Rapid Mood Screener, the recently validated screening tool for bipolar disorder.
Third and finally, let's integrate the care. Again, above the neck and below the neck, take care of not just the mental health but the physical health, because unless you have both of them along with social well-being, you don't really have health, and that really is the call to action in this population.
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