The Best Treatment for Bipolar Depression and Symptomatic Interventions With Dr Tohen

Mauricio Tohen, MD, DrPH, University of New Mexico School of Medicine, Albuquerque, New Mexico, gives the main takeaways from his recent American Psychiatric Association 2022 Annual Meeting session titled, "Bipolar Depression: Outcome and Pharmacological Treatment." He explores the primary challenges for clinicians working with patients with bipolar depression, diagnosis, pharmacological and neuromodulation treatments, and more.

Watch Part 1 of the video series here!

Mauricio Tohen, MD, DrPH, MBA is university distinguished professor and chairman of the Department of Psychiatry & Behavioural Sciences at the University of New Mexico HSC in Albuquerque New Mexico. In 2014 Dr Tohen was recognized in Thomson Reuter’s “The World’s Most Influential Scientific Minds, 2014”. He is one of 100 scientists worldwide recognized in the psychiatry/psychology category. Dr Tohen has published over 350 publications and has over 20,000 scientific citations. In 2016 the International Society for Bipolar disorders awarded him the Mogens Schou Award for Education and Teaching. In 2017 and again in 2021, Dr Tohen was Recognized by Expertscape as having the top % 0.12 expertise in bipolar disorder worldwide based on citations of published articles between 2007-2017 and 2010-2021

Read the transcript:

Meagan Thistle, Associate Digital Editor, Psych Congress Network: Absolutely. So if you have anything else you'd like to add on the topic of the use of antidepressants in bipolar depression, we would love to hear more thoughts on that.

Dr Mauricio Tohen: Sure. Before I do that, let me just mention that If you ask me the efficacy of the typical antipsychotics, I wish I could say, "Yeah, everybody responds to them." The answer is not. It is about 60% of the patients have a response. And there's still some patients who don't respond to monotherapy. There's some studies that have shown use of the atypical antipsychotic and mood stabilizers, such as lithium and [valproic acid] has that with those treatments, and that is quite promising. Let me get back to your last question, Megan, and that is the use of antidepressants. I've mentioned that the main problem with the antidepressants—the tricyclics, SSRIs, NRIs—is that they just, in monotherapy, they do not have efficacy in bipolar depression. So unfortunately, patients are misdiagnosed. For instance, in our treatment-resistant depression clinic, the first differential diagnosis that we always have is rule out bipolar depression. That is the first differential diagnosis that we always look for.

Now, there was a lot of debate in terms of our anti-depressants contraindicated in the treatment of bipolar depression. The answer is they're not absolutely contraindicated except in monotherapy. In monotherapy, I would say they're contraindicated. Number one, they don't work. But number two is primum non nocere. It's, "don't harm our patients." Not only do they not work, but they can actually induce mania and create rapid cycling. So monotherapy of antidepressants, not contraindicated in monotherapy. Now, in combination with atypical antipsychotics, that is a reasonable use. In general, if a patient is not responding to, say an atypical antipsychotic, would it be reasonable to add an antidepressant? That could be one approach. So they can be utilized.

The other question is, what about on maintenance? And that's also, to some extent, more of a risk because the maintenance of course is longitudinal. And I would say to use it very cautiously. The only time that I would use the antidepressants, even in combination with an atypical antipsychotic, would be if there is a history in a particular patient where the discontinuation of antidepressant actually cause relapse. And you can see that. Patient treated on an antidepressant and atypical antipsychotic show good efficacy. And then of course, we try to be parsimonious: the least number of treatments, the best. That's what's best for the patient, because you'll avoid side effects. You discontinue the antidepressant and then you can see relapses. So when you have a patient with that history, then continuation of the antidepressant would be reasonable.

Now you haven't asked me Megan, but if you ask me, what is the best treatment for bipolar depression? The right answer is: depends on your patient. You can't really say A is better than B, or X is better than Y antidepressant. It really depends on the patient. Previous respond or lackethereof to that treatment, family history--that's a key question. When we have a patient with bipolar depression, "do you have a family member with bipolar depression?" The answer, "Yes." Immediate next question is "What treatment has your family member received and what was the response and tolerability?" So that would be key in terms of the treatment of bipolar depression.

Thistle: So continuing off of that, what advice would you have for clinicians? If you ask those questions and you try out a treatment plan and it doesn't work, that first option. What advice would you have for clinicians in that position?

Dr Tohen: Unfortunately the scenario that you present is not that unusual, and unfortunately we don't have personalized medicine where we can get a biomarker and determine what is going to be the right antidepressant or what's going to be the right treatment for this patient. We don't have that. It's going to happen in psychiatry, that we have personalized medicine. We don't have it yet. There's been some studies. So, we're still in trial and error.  And actually one of the tools that we use is what I've mentioned before fact, so-called pharmacogenetics. If there's family members with a condition, what treatments have they responded to or not, or what treatments theres’s been tolerability or not? That would be the first step.

The other thing is, don't give up too quickly. Because if you started treatment—and actually, this is part of the psychoeducation with the patient—is that if there's no response in a couple of days, the last thing you want to do is stop the treatment at that point, unless of course there are side effects, because if the duration has been long enough, in a way you've wasted that time. You want to make sure that when you rule out a specific treatment, it includes the duration of the treatment and also the dose. Dose would be key things. Stopping treatments is always a risk. So what I prefer to do, if I start treatment, do I move for something right away? Well, in some cases. But the other one, if you have a response adding a second treatment, is that reasonable? It can be reasonable, especially if there's tolerability. That of course prevents the stop of a treatment. That of course carries risk of recurrence, especially it there's abrupt discontinuation of treatment. So that's why we need to be very thoughtful on how to go about the next step. Do it slowly, if you're going to stop at treatment. Sometimes you can piggyback, as long as there's no drug interactions. Just be very careful when you're switching treatments.

Thistle: Well, thank you. I know our audience of clinicians will benefit from that advice. As we round out our time together, are there any misconceptions on any of the topics you presented that you'd like to clear up? Or any other final thoughts that you have on this topic?

Dr Tohen: Well, all the treatments that we talked about are symptomatic. We have no curative interventions in psychiatry. And many times, especially when we're talking about maintenance treatment with my patients, and that one of the first questions even with first episode is "Doc, how long will I be on my treatment?" With a first episode, you can consider discontinuation at some point because there's a few very fortunate ones that is a single episode only. But let's talk about patients who've had more than one or two episodes. The right answer to how long will I stay on my treatment is "As long as it helps you and you tolerate it, you'll stay on the treatment until we find a cure." And I'm hopeful that within our generation, we will find better treatments than we have now. We're doing better than in the past, but we certainly have a long way to go.

Thistle: Yes we do. But I know with the dedication of folks such as yourself, we'll get there. Thank you so much again for your time.  And, to our audience at Psych Congress Network, please make sure to check out our APA newsroom for updates from the meeting, as well as our bipolar excellence forum and bipolar topic centers for resources all year round. So thank you again so much Dr Tohen.

Dr Tohen: Well I thank Psych Congress Network for the invitation. It was my pleasure and honor. Good seeing you colleagues. So long.

Thistle: Thank you.