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Understanding Polarity-Proneness in Patients With Bipolar Disorder
(Part 3 of 4)
In this video, Joseph F. Goldberg, MD, explains the concept of polarity-proneness and why clinicians should assess it when treating patients with bipolar disorder. He also discusses the concept in his session titled "Bespoke Psychopharmacology: Tailoring Individualized Pharmacotherapy for Patients with Bipolar Disorder" being presented at the 2021 Psych Congress Regionals meeting series, which continues April 23 and 24 and May 21 and 22.
Dr. Goldberg, Clinical Professor of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York, is a Bipolar Disorders Section Editor for the Psychiatry and Behavioral Health Learning Network.
Some years ago, the observation was made that, if you're life-charting a patient with bipolar disorder over time that is starting from the present episode and working backwards, "I know you're now depressed or you're now on a high. What was it like before now, and what was it like before that?"
Try to sketch out at least the last 6 months, ideally the last 12 months. Ideally, ideally, going all the way back to your first illness. You can gather a lot of useful information about a given patient just by spending that time on the front end constructing their history.
Someone who's had 7 episodes versus 1 or 2 has a different course in store. Someone who's had many highs over their clinical career versus many lows is also going to have a different moderating presentation for their illness.
When we count out episodes over time, we ask, "Are they 50-50 up and down, or is there is a predominance for one polarity over the other?" Most people—not all, but most people with bipolar disorder—will spend more time in the southern hemisphere than the northern hemisphere, and their full-on episodes may involve more depressions than highs.
This factors into treatment decisions, because a lot of our medicines tend to be more impactful on the high side than the low side. Lithium, for example, the gold standard mood stabilizer, works particularly well in a mania-prone patient or in a patient whose manias precede their depressions, then followed by an intermorbid period.
Whereas someone who's more dominantly depressed phase-prone or has more depressions that are the driving force, or that lead from depressions into manias, antimanic mood stabilizers like lithium may not be as effective, or agents like divalproex or carbamazepine.
Then I think I'd mentioned in the presentation a very recent study in the Journal of Clinical Psychiatry actually suggested that the potential for seeing someone's mood to switch, not from a depression to a mania, but from a mania to a depression—the other kind of switch—may be somewhat more of a liability with at least some antipsychotic drugs if their polarity-proneness is more toward depression.
For the clinician, this means you don't just want to say, "OK, you have bipolar disorder, and your present mood episode is manic, mixed, or depressed?" but where have you been at least over the last 6, if not 9 or 12 months, to judge the likelihood that someone's driving process of their illness is more on the upside than the downside.
Patients who are more driven on the upside may be excellent candidates for lithium, divalproex, carbamazepine, and maybe just about any second-generation antipsychotic, whereas those who are more dominantly driven by depression may be better candidates for lamotrigine, possibly some of the second-generation antipsychotics that have known value for bipolar depression.
Although most of those studies are acute, not maintenance. Lithium by itself may not be as useful for a depression-prone patient, so really worth taking the time to establish over at least the recent history what the phases have been and whether or not there's been a lot of polarity change or dominance on one side versus the other.
Distinguishing Between Bipolar I Disorder and Bipolar II Disorder
Using Moderators and Mediators to Tailor Bipolar Disorder Treatment
