COMMENTARY

A Guide to Managing Bipolar Disorder

Stephen M. Strakowski, MD, PhD

Disclosures

April 07, 2015

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Hello. I am Dr Stephen M. Strakowski, professor in the Department of Psychiatry at the University of Cincinnati in Ohio. I am also senior vice president at our affiliated health system, in charge of strategic planning. Today, I want to talk about a programmatic approach to managing bipolar disorder. In particular, I want to focus on how to develop systematic follow-up appointments to manage this complex illness.

Bipolar disorder by its very nature is dynamic. It is easy to be caught up in the bipolar pattern of symptoms and to find oneself chasing symptoms and the constant changes in the condition rather than proactively managing the illness. In this process of developing a systematic proactive management plan, I believe we can also teach our patients how to proactively manage their symptoms and their concerns. This requires a structured approach for managing appointments, and this structure requires background information that I will assume you have already obtained.

This strategy first involves a comprehensive assessment of the patient's illness, to be sure we understand the specific bipolar condition and know that it is truly bipolar disorder; we need to have family history substantiating the condition; and we need to know about the patient's drug and alcohol use, and medical problems. Next, we need to have ongoing safety assessments to understand the patient's risk factors for suicide or other dangerous behavior.

At some point before setting up appointments, we want to formulate clear treatment goals so that we know what we are trying to accomplish. We want to have built a support network for the patient, and finally, we want to make sure we are using our appointments to effectively manage symptoms. Using that kind of background information, how do we create a meaningful appointment so that we can do the work that is necessary to manage this complicated illness? In the current medical environment where we are often pressed for time, this becomes extremely important for these complicated patients.

First, it is essential to be friendly. We want to engage in friendly conversation, but we also want to be careful at the very beginning that we do not allow random chit-chat to eat up the entire appointment, which often is limited to 20 or 30 minutes, or less in some settings. We need to strike a fine balance to show that we enjoy meeting with our patients, which is why we do this work, while also getting down to the business of managing bipolar disorder.

One of the key features of managing bipolar disorder is to develop some kind of mood chart on which patients record their worst depressive symptoms or their worst manic symptoms or any other key symptoms each day, so when they come to appointments, these symptoms are laid out graphically and changes are easy to assess. Several of these mood charts are available online, and there are even a few phone apps.

I like to use the mood charts that can be purchased for about $1 from the Depression and Bipolar Support Alliance. These enable patients to become accustomed to recording their symptoms and keeping track of these themselves. They also provide a quick review of how the patient is doing and adds metrics to the assessment. Moreover, this kind of chart allows you and the patient to work together collaboratively to see whether treatments are working.

Safety and Adherence Assessments

Once we have reviewed the mood chart and seen how things have been going since our last appointment, it is important to evaluate safety, to assess any suicidal risks, any triggers or protective features, and to make sure the patient is safe to continue management as an outpatient. Within the mood chart, I often ask patients to record whether or not they are following their medication regimens. I have found that it is easier for them to admit to missing medication doses when they check a box on a form than when they have to verbally bring it up for the first time. Then we can nonjudgmentally look at why they have missed medication doses: for example, if the regimen is too complicated, or if some feature in their lives make it difficult to follow the particular regimen. This also enables us to quickly relate how often symptom changes follow missed medication doses.

During this part of the discussion, it is important to review side effects, which are often responsible for adherence problems. It is critical to ask about sensitive or embarrassing side effects, such as sexual dysfunction, which is common with many of these medicines. People often will not spontaneously bring up sexual issues, but they will stop taking the medication because of this and may disappear from follow-up. The care provider has the responsibility to ask about adverse effects of all kinds.

Review of Systems

Do not forget to conduct a medical review of systems, to be sure nothing new is going on. Always ask about drugs, alcohol, and cigarette use of course. One key part of bipolar management is to assess and encourage good general health measures, particularly for patients with bipolar disease, for whom social and circadian rhythm disruption can be a major precipitant of episodes. Include in the mood chart a record of how much sleep patients get each night—what time they go to bed and what time they get up. When and how do they exercise? What kind of diet are they following? Keep track of weight, because many of our medicines affect how we eat and can cause weight gain. This can be included in the mood chart and can be managed in a few minutes each night by our patients, but it can be a big help during the appointment as we look at the longer-term course of illness.

I cannot emphasize enough how important these mood charts are. They provide a long-term look at how useful a medication is for a given patient.

The mood chart also gives patients a chance to feel in control in monitoring their symptoms rather than being driven by them. In addition, because we are emotional beings, we tend to interpret our world by our current mood state. Without a 30-day history of what my symptoms have been like, I will tend to recount them on the basis of how I feel right now. If I am having a bad day, I may remember the month as much worse than it was. Conversely, if I am having an unusually good day, I may recount the last month as being better than it really was. This steady history recorded in a mood chart can be quite helpful for patients to see their true progress.

Adjusting Medications

Reviewing the mood chart and general health and other issues typically only takes a few minutes, unless there are significant problems with medication or within the person's life. When I talk about medication changes with patients, I set a goal of not exceeding three medications to manage symptoms. There will be exceptions to that rule but, in reality, our clinical studies in bipolar disorder treatment have rarely included two medications and almost never have used three medications.

Once you get past two or three medications in a single patient, you have ventured into a world with no scientific data or medical support. The adverse effect risks increase. In fact, if you are using four or five medications, almost certainly two or three of them are not doing anything other than adding side effects. Thus, as a general rule, I set a three-medication maximum.

I try to use the mood charts to enhance our understanding that medications do not work immediately, but maximize benefit over time. At each appointment, we evaluate whether a medication is absolutely necessary, and what is the benefit; if it is not beneficial, then we work on discontinuing the medicine and trying something else. With this systematic, deliberate approach, I have found that virtually all patients can be managed with no more than three medications. We need to have a systematic trial-and-error process to decide whether a medication is valuable.

Cognitive Behavioral Skills Are Important

I encourage even psychopharmacologists to develop some kind of behavioral skills—to develop homework for patients to apply cognitive-behavioral therapy, which is a very useful adjunct in the management of patients with bipolar disorder. Backbone mood stabilizers are critical, but the addition of behavioral therapies, social rhythm management, and circadian rhythm management can go a long way toward that goal of minimizing medication exposure.

Finally, even with all of this, I believe you can still have 5 minutes or so left for patients to ask questions. At the end of every appointment, I ask my patients whether they have any questions, or whether we have done anything today, or assigned any homework, or made any medication changes that the patient does not understand. One of the nice things about electronic medical records is that you can print out the treatment plans, give them to the patient, go over them together, and answer questions at the end of the appointment.

Again, each of us has to find our best way to manage appointments, but I believe that by being systematic, we introduce some predictability into a chaotic illness and do not chase symptoms, but rather manage them proactively. Doing so will maximally benefit our patients, and ultimately that is our goal.

If you are interested in this approach or want to learn more about it, my book, Bipolar Disorder,[1] published by Oxford University Press, describes it in more detail.

Again, I appreciate your time today. I hope that you found this useful. Thank you very much for turning to Medscape for this psychiatry information.

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