Managing Patients With Bipolar Disorder

In part 2 of this 2-part episode, W. Clay Jackson, MD, DipTH, speaks about the challenges of managing a patient with bipolar disorder and the gaps in the research of bipolar disorder. 

For more information on bipolar disorder, visit the Resource Center. 

Listen to part 1 of this 2-part episode here. 

W. Clay Jackson, MD, DipTh, is an assistant professor of clinical psychiatry and family medicine at the University of Tennessee College of Medicine (Memphis, TN).

TRANSCRIPTION:

Jessica Bard: Hello, everyone, and welcome to another installment of Podcast 360, your go-to resource for medical news and clinical updates. I'm your moderator, Jessica Bard with Consultant360, a multidisciplinary medical information network.

Nearly 83% of people with bipolar disorder have serious impairment according to the National Institutes of Health. Dr. Clay Jackson is here to speak with us today about bipolar disorder. Dr. Jackson is an Assistant Professor of Clinical Psychiatry and Family Medicine at the University of Tennessee College of Medicine in Memphis, Tennessee. Thank you for joining us today, Dr. Jackson. How should a patient with bipolar disorder be managed?

Dr Clay Jackson: With respect, a patient with bipolar disorder should be managed as a person with a medical condition, not as an interesting case study or someone to be kept at arms' length in terms of clinical expectation. They should be treated with care. These are complex, psychiatric symptoms, and sometimes bipolar disorder in our medical path has been overdiagnosed, more commonly it's been underdiagnosed. And typically, these patients have a great deal of suffering that they accrue through their treatment journey and their clinical journey of their experience.

These patients often suffer their symptoms for about 10 years before they receive a proper diagnosis so they can sometimes have some lack of therapeutic alliance or confidence, they may even be a little bit jaded about diagnosis and treatment. And so sitting down with some real old-fashioned psycho-education and saying, "Hey, we think this is what is happening with you, we think there's adequate treatment for you," and establishing that therapeutic bond can be incredibly helpful because nonadherence to an agreed-upon plan is a particular challenge of bipolar disorder. So investing some time on the front end with the patient to make sure that they have an understanding of what you think is happening, and that they agree with you about the treatment choice and that they are enthusiastic about that treatment choice, can be very helpful and save a lot of time on the back end in terms of adherence challenges, et cetera.

Jessica Bard: I know you said this is a hot-button topic here, the gaps in research in bipolar disorder, what are those gaps in the research?

Dr Clay Jackson: Oh wow. Genetic polymorphisms that predict the onset of bipolar disorder, the early life adversity issues that can set up inflammation in the human body and brain that can impact bipolarity, both in incidence and severity, developing pharmacotherapeutic agents, which are efficacious for the illness symptoms and yet have a low adverse event profile. That's sort of the Holy Grail of pharmacology for bipolar disorder patients because we have lots of things that work, and we have lots of things that work pretty well, but many of those agents are associated with perturbations in the metabolic profile, weight gain, glucose disturbances, lipid disturbances, some of the medications are inappropriately sedating. So there are a number of challenges with pharmacotherapy.

If we look at non-pharm therapy or non-pharmacologic interventions such as exercise, meditation, talk therapy, psychotherapy of various kinds, these are helpful in bipolar patients but it's a little bit more nuanced than it is let's say with major depression disorder because a patient, say for instance, that is in a mixed state, might actually have their symptoms worsened by exercise, not improved. But a patient who's on the depressive end of the disorder might have their symptoms greatly improved with exercise.

So it's a little more challenging, and some of these areas are certainly wonderful, wonderful areas for advancement of research. In terms of development of the armamentarium, we sort of have the classic monoamine hypothesis of affective disorders, where we focus on dopamine, serotonin, and some of the other monoamine neurotransmitters. And yet the role of GABA, the role of glutamate, remains to be fully elucidated in terms of the treatment of bipolar disorder.

A little bit to comb down even a little more specifically, medications that affect bipolar depression are in poor supply. We only have about four of those that are approved for the treatment of bipolar depression, and then medications that can be used in pediatric patients. For obvious reasons, pediatric patients are not the first to typically be signed up for registration trials. And so an increase in understanding in agents that might be helpful if pediatric patients would certainly be laudable. And then some of the metabolic disturbances of pediatric patients can be even more pronounced, and so agents that would sort of have a metabolic light touch in the pediatric population would certainly be welcomed by all in the therapeutic community.

Jessica Bard: What would you say are the key take-home messages from our conversation today?

Dr Clay Jackson: Bipolar disorder is treatable. These patients suffer and they suffer markedly. Even if they're on the so-called softer bipolar spectrum, which typically doesn't result in hospitalization or psychosis. If we're talking bipolar II or NOS, those patients can still have significant, significant vocational and relational challenges, sort of this idea of ratcheting down in terms of the expectations of what their achievement and personal satisfaction can be or winds up practically being in life. That's tragic. Human potential is lost, human suffering is exacerbated by inappropriate or misdiagnosis of these patients, lack of diagnosis, and then inappropriate treatment, inappropriate lack of compassion and understanding.

So if we weighed in as clinicians and we value the experiences that these patients, we listen to them, we learn from them, we sit with them in empathy and mutual respect, and form a positive and robust therapeutic alliance, with the pharmacologic and non-pharmacologic tools that are at our disposal in the 2020s, our decade, I think that there's great hope for these patients, and there's great hope for us as clinicians who treat them, that we can significantly improve these patients' experiences and that benefits all of us because we're all, ultimately, part of the same community. And that's a hopeful message that I hope my colleagues today will take to heart and will take to clinic.

Jessica Bard: Is there anything else that you'd like to add today?

Dr Clay Jackson: It's an exciting time to be in psychiatry. It's an exciting time to be in primary care. There are new pharmacologic pathways that are open to us. There are new treatments that are in development. There are new understandings of how to use even the treatments that we have in terms of improving adherence. There are new ways of understanding patients. We're learning to listen with more open ears. Rather than being completely paternalistic and sort of hierarchical, we're learning to be more collaborative, and more open to hearing from patient input, and that improvement of the therapeutic alliance offers me great hope for the future for patients who suffer from this devastating disorder. Thank you so much for having me on today.

Jessica Bard: Thanks for being here.