Preventing the Progression of Bipolar Disorder

In this video, Robert M. Post, MD, discusses the need for early intervention in bipolar disorder, steps which should be taken after a patient’s first manic episode, and factors to consider when choosing a mood stabilizer for a patient with bipolar disorder.

Dr. Post, Clinical Professor of Psychiatry, George Washington School of Psychiatry, Chevy Chase, Maryland, presented information on these topics during his session “Critical Role of Pharmacotherapy in the Prevention of Bipolar Disorder” at the Psych Congress 2020 psychopharmacology preconference held virtually Sept. 9, 2020.

Read the transcript:

My name is Robert M. Post. I'm from Bethesda, Maryland. I run the Bipolar Collaborative Network there. I'm also the editor of a free newsletter that patients and docs can access on www.bipolarnews.org. It has all of the latest things that I learn about from meetings and the literature in that. Patients and docs seem to find that quite useful.

I'm also trying to enhance the early recognition of this illness because in the United States, there's a lot of childhood-onset illness, which is a poor prognosis illness, in part because it starts early but also because there's often a long delay to first treatment.

We have a child network that people can also access on that same website if they click on "Child Network." We're hopeful that patients can get more and more educated about this illness, including the need for early treatment.

Why is early intervention needed for patients with bipolar disorder?

This is a critical issue because the illness tends to be progressive. The more episodes one has, the more problematic the illness becomes. Relapses occur faster. If there are too many relapses, ultimately patients become treatment-refractory. Intervening early and heading off the illness early is a key to a good long-term outcome.

What steps should be taken after a patient's first manic episode?

This is an area where there's not enough emphasis. People don't take that first manic episode seriously. After the first manic episode, one should have increased attention to preventing relapses from thereafter.

There's new data from Lakshmi Yatham in Vancouver that one has cognitive deficits after the first mania. These normalize over the next year but only under the condition that there are no further relapses. There are other studies that support these same data.

It's crucial after a first manic episode to get the patient into good long-term prophylaxis and prevent any more episodes from occurring. This is not so easily done, but it needs to be much more urgently looked at as one of the first things to do with a new-onset bipolar illness.

This also would help head off the high risk for substance abuse and other problems that come with the first episode. Treating it as almost a medical emergency is the way to do it and to do it with both therapy, psychotherapy and pharmacotherapy, and using enough meds as is necessary to maintain a remission.

Which factors should clinicians consider when choosing a mood stabilizer for a patient with bipolar disorder?

This is a key issue. One of the issues is that the data indicate a much better long-term prophylaxis when these drugs are used in combination. If one uses lithium, for example, it's often useful to combine this with an anticonvulsant mood stabilizer or an atypical antipsychotic that has efficacy in the depressive phase of the illness.

The choice of mood stabilizers is not explicitly outlined in the literature, but there's a number of suggestions that patients with a positive family history for bipolar disorder or mood disorders in general are more likely to respond to lithium.

Carbamazepine is the other way around. It tends to be positive in patients without a positive family history of bipolar disorder. Interestingly enough, lamotrigine, in the Canadian studies, seems to go best with patients who have a personal or family history of anxiety disorders.

The other important thing is that if patients are from a family that are not lithium-responsive, this may be a good use to think about an atypical antipsychotic. The family history can help in the choice of these meds.