Tailored Treatment Plans and Challenges for Bipolar Disorder

In Part 2 of this video, Heather Flint, senior digital managing editor, Psych Congress Network, sits down with Psych Congress Steering Committee Member Craig Chepke, MD, FAPA, Medical Director, Excel Psychiatric Associates, Huntersville, NC, to address tailoring treatment plans and offers his insights on the biggest challenges for other clinicians when treating patients with bipolar disorder.

In Part 1, Dr Chepke discussed correctly diagnosing bipolar disorder as well as nonpharmacological therapies to incorporate into their treatment plan.

Read the Transcript

Heather Flint:  What treatment combinations have you found to be most beneficial for treating bipolar disorder? How important is it to tailor a treatment plan to each individual patient?

Dr Craig Chepke:  I'll take the last question first. Every patient, no matter what their diagnosis is, no matter who they are, it's important to tailor the medication treatment to them and the non-medication treatment to them as well. Personalized medicine should be everyone's goal.

We should be looking at a person-centered model, shared decision-making because there is no cookie-cutter approach in psychiatry. It doesn't work. I don't know if it does in any part of medicine, but psychiatry at least amongst all because everyone is so different.

There's a great quote by Dr William Osler, "It's more important to know the person who has a disease than to know what disease a person has." I think that couldn't be more true. We have to figure out who this person is, what makes them tick, and what's going to work for them.

Not just say, "Oh, yeah. The guidelines say first line, I do this. Second line, I do that," because it might not be right for them. We have to take into account their preferences, and what they want out of treatment, what their goals are, and how the medications can help them achieve their goals, and be in accordance with their preferences.

Guidelines are important and in terms of -- to come back to your first question -- the combinations. If I could get every single patient with bipolar disorder on lithium, I would do it. That's become harder and harder, even in my career. I found that lithium, valproate, as well as mood stabilizers, it's getting harder and harder I found to get patients to accept those medications.

We could go into a long discussion as to why I think that is, but that's what I've seen anecdotally. I do think that most patients these days tend to do well with a combination of a mood stabilizer and a atypical antipsychotic that often we have to mix and match because not all treatments for bipolar disorder work equally well on both polarities.

Some only work for mania, some only work for depression, some may have some efficacy in both. Often, we have to cobble together something that works for depression and that works for mania as two separate agents. Those would be the common combinations, but I do stay away from, as much as I can, is traditional antidepressants, SSRIs, SNRIs.

Those are not evidence-based treatments, even though they are the most common treatments statistically that are prescribed for patients with bipolar disorder. The classic fear is that they could make someone manic.

That is less common with the more recent antidepressants like SSRIs, but they can cause increased cycling rate and increase, not just manic, but increased depressive episodes by much of the evidence that we have. That's one combination I do try to stay away from.

Heather Flint:  What are the biggest challenges to treating patients with bipolar disorder? What would you give as tips or other information to clinicians to overcome these challenges?

Dr Chepke:  I described a backdoor way to some of the challenges with the medications acting unequally on one type of mood episode versus the other, the adherence that I mentioned. With the comorbidities, most commonly, there's ADHD. There's substance use disorder. Anxiety is extremely prevalent. Binge eating disorder as well.

A lot of things that can be related to dopaminergic dysfunction in many cases. It comes back to that shared decision-making that if we can elicit the goals that the patient has in life.

These patients don't come in and say, "Hey, you know what, doc? What I really want is to have this score on my clinical trial rating scale reduced." No. They come in and say things like, "I want to get my life back. I want to be a better husband, a better father. I want to go back to school. I want to go back to work," the functional type of outcomes.

Finding out what makes a person tick and what their goals are, if we can find a medication that will help them achieve those goals, then they're going to be more likely to want to stick with the treatment. If we're educating them well on all the risks and the benefits, then if a road bump does come up, they get a side effect.

"Oh, yeah. You told me about this. You said there are ways we can manage it. I just wanted to call you and find out, what do we do about this now," as opposed to what often happens if they're not informed, they stop it. Then they tell you a month, two months later, maybe they might not tell you.

There have been cases. This was in one of my presentations that I presented here that a patient was referred to me that was discharged from the other psychiatrist's practice because he had not taken any of the medications that he was prescribed for three years. He kept coming back to the visits over and over again.

He would come back to visits, and then finally revealed, he had not taken any medications except over-the-counter one for sleep for three years. We have to figure out how to get a treatment regimen for the person that they agree to, that they want to take, and even then, it's not going to be perfect.

That's our best shot at getting someone to take the medication, which is the best way that we have to try and prevent those future relapses. Again, I'll throw it out there. If the person is agreeable to long-acting injectable antipsychotic, even if they're not, we should at least be offering that to patients and informing them that it is an option for them.

Heather:  Excellent. Thank you so much for taking the time to sit down with us today and discuss your sessions and give us more information about bipolar disorder.

Dr Chepke:  Thank you.