Bethanie Simmons-Becil, DNP, MSN, APRN, PMHNP-BC, APHN-BC

Bethanie Simmons-Becil, DNP, MSN, APRN, PMHNP-BC, APHN-BC:

The roundtable discussion was fantastic. There was a variety of different types of providers. We had both psychiatrists, medical doctors, and psychiatric nurse practitioners present, and it was great to see and to hear the different points of view and the styles of treatment from my peers in the community. I really enjoyed being able to provide additional research, especially newer, more relevant research on presenting symptoms and best practices for diagnosing and identifying bipolar in the community. I enjoyed that there was open discussion about medications to use and everybody was very comfortable in sharing their preferred medication and why it was preferred. It was interesting to watch several of the providers kind of raise their eyebrows. That's something new. I might need to try that. It impressed me and it gave me hope for the psychiatric community, specifically for those of us who prescribe in the psychiatric community, just because the more we work together, the better we do for our patients. The more open communication we have as providers, the less stigma there will be associated with bipolar disorder and the more willing patients might potentially be to seek help. Further, for those of us who meet each other in the community and work together, we can also realize that we are not alone in this battle, either, and that we have valuable peers, educated professionals that can support us and work with us to help ensure best outcomes for all of our patients.

As an advanced practice educator, one of the biggest gaps I see in care of patients with bipolar disorder predominantly is consistency of management. There are different styles. Every provider has their own style and treatment and how they work with their patients and there are different types of education. Medical doctors receive very disease-focused education as that's part of the medical model. Whereas nurses receive very holistic patient education regarding symptomology to where it's not necessarily just a diagnosis, but it's all the environmental impact. What I think needs to happen for us in psychiatry is we need to combine those 2 thoughts together. We need to identify that bipolar disorder is truly a medical diagnosis and that it has enough research to support common symptomology and common presentation, which helps with ease of diagnosis. The biggest gap that I find both on the psychiatry side, as well as the nurse practitioner side, is that we tend to prescribe based upon diagnosis. As a prudent prescriber and as someone who loves the work of Dr Stephen Stahl, MD, PhD, and understanding neuroanatomy, we really need to focus our efforts on identifying the presenting symptoms of the individual because not every patient presents the same. If we focus on the presenting symptoms of the individual and we connect that to our knowledge of the brain and to the neuroanatomy and to what neurotransmitter may be in flux for that particular patient, we will prescribe more efficiently.

When a patient is presenting manic or hypomanic, we know that that's rooted in the excess of [dopamine receptor] D2 and D3. You would want to pick a medication that is going to be more focused on D2 and D3 to modulate that and help bring that patient to a more consistent level. Conversely, if you have a patient that is presenting with predominant depressive symptoms, again, we connect that to partially D2 but also serotonin. We pick a medication that modulates both that D2 and that serotonergic aspect so we don't get caught in that trap of, “OK, well, I've diagnosed you with bipolar depression so these are the only 4 medications that are approved for depression,” and those are going to be what I use because it's not a cookie-cutter model. We work in psychiatry at a detriment because there's no lab, there's no scan. There's nothing tangible that I can assess to give a finite diagnosis. It's all based on my perception and patient report. There can be so much variability in that treatment, but if we truly focus on the symptom presentation of that patient, and we tie that to our knowledge of the brain and how those symptoms are evidencing themselves and how they're connected to those changes in the brain–our medication selection is based upon that knowledge. Then, we will be more prudent providers and we will choose medications that are more appropriate for that particular individual, rather than that individual's diagnosis.

I thoroughly enjoyed the event. I was impressed with the professionals that were brought together for the case study, and I thoroughly enjoyed having multiple different perspectives and opinions in the same room because it allowed us to have open, comfortable conversation with our peers about best practice for bipolar patients. I think that moving forward, events like this can significantly improve the consistency in treatment for bipolar disorder, as well as a sense of collegiality among those who work in psychiatry. I think that with these particular types of events, the more they happen, the more attended, the more folks that are willing to take a moment and listen, I think that it will significantly improve not only our experience as psychiatric providers but our clients’ experience that come to us in need. Thank you so much for your time today. I sincerely appreciate the incredible opportunity that I had in moderating this event and being part of future education.

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A psychiatric nurse practitioner shares gaps in care in bipolar 1 disorder treatment.

Unmet Needs in Bipolar Disorder Management

Bethanie Simmons-Becil, DNP, MSN, APRN, PMHNP-BC, APHN-BC: 

In any mental health diagnosis or any mental health treatment, patient communication and education is incredibly important. Oftentimes, these patients have been to their primary care providers on at least 2 or 3 occasions before they make it to those of us that specialize in psychiatry. We really need to make sure we understand the implications and the ramifications of their disease. A lot of patients are not happy with the diagnosis of bipolar disorder. There's a lot of social stigma involved with bipolar disorder mostly because of social media. We only get to see those folks that have the worst of the worst. It is always a struggle when you tell a patient, especially for the first time, that, “I think that you might have bipolar disorder.” Sometimes, it's important to educate them that bipolar disorder is a functional disease. You don't have to go on disability, you don't have to be out of work. You don't have to give up your life. These are conditions that can be managed and managed well with medication and have little impact over time, especially if you maintain treatment and regular therapy, which is always incredibly helpful. I really encourage my students and my peers to really provide the patient with a true understanding of what bipolar disorder is, which is that it's simply just a modulation, a shifting of moods.

My job in the situation is to one, help them identify when they're having prodromal symptoms when things are starting to crop up and catch them before they come back, become worse, or also help them understand that this is a diagnosis that's wholly their own. They don't have to share this information with anybody else. They don't have to be embarrassed by their situation, and it's helpful for them to have more education and to take it upon themselves, to educate themselves about their disorder. I really enjoy giving handouts and websites for NIMH, the National Institute of Mental Health, or NAMI the National Alliance for Mental Illness. I make sure that they have access to handouts here in my office to kind of educate them on the presenting symptoms and how to kind of catch things before they come about. Also, try to make sure, especially for those that don't have a good support system in their community, to give them references to community support groups, not just NAMI, but also, open group therapy and things that might be more beneficial, especially if they're starting to struggle with social isolation or feeling lonely because of their diagnosis. A lot of it for me is when I'm speaking with someone who has bipolar disorder and may not fully understand their diagnosis, I really try to meet them where they are and give them as much material and education as they're willing to receive just so they know that they can continue to live a normal, functional life.

Bethanie Simmons-Becil, DNP, MSN, APRN, PMHNP-BC, APHN-BC, highlights the importance of patient communication and education when treating bipolar 1 disorder.

Role of Patient Education for Bipolar 1 Disorder Treatment

Atypical antipsychotics for patients with bipolar disorder are generally indicated, especially those that are FDA [Food and Drug Administration] indicated for treating bipolar mania, depression, or mixed features. When we're talking about someone who is over the age of 65, we know that atypical antipsychotics have a significant amount of black box warnings that can contribute to more cardiovascular issues and falls for this particular population. However, in this particular patient's case, she was effectively maintained on lithium for quite a long time. Right now, we're not so worried about her manic or hypomanic episodes. We're more focused on her depressive episodes. The potential to add on an atypical antipsychotic could be very effective and potentially replace the lithium especially if we use a more advanced medication–a newer medication to treat those particular symptoms so basically that we would be able to replace lithium with an atypical antipsychotic that's able to manage both the mania–hypomania features as well as the depressive features and have less potential for interaction among the medication she's already taking.

At this point in time, there are only 3 or 4 medications on the market that are specifically indicated for bipolar 1 depression. Of those, they are atypical antipsychotics and they also carry that black box warning, especially for those over the age of 65. For this particular patient, in this case, you would want to make sure to choose a medication that will play nicely in the sandbox, so to speak, with the other medications that she has onboard and not potentially increase her risk of adverse drug reactions such as falls or increased UTIs [urinary tract infections] or confusion. When we're talking about medications in that aspect, we also want to think about the symptoms and how they present for this patient. With a history of mania or hypomania or thinking of things when we're talking about neurotransmitters like dopamine receptor D2 and D3 and then serotonin 5-HT2A and 1A and 2C, when we're thinking about those particular neurotransmitters, we want to make sure that we select a medication that is going to work at the root of the patient's presentation. For someone who's presenting with more depressed features, we want to consider a medication that's going to work both on serotonin as well as dopamine so newer medications as Dr. Stephen Stahl, MD, PhD, refers to as “Two Pips and a Rip”. We're talking about aripiprazole, brexpiprazole, and cariprazine. Those medications have less interactive medication profiles where they don't necessarily interact with other meds the patient may be taking. Those might be a better option for this particular patient, considering the metformin, Invokana [canagliflozin], olmesartan, the rosuvastatin and the PRN nitrofurantoin that she's taking.

For patients with bipolar disorder whether it's bipolar 1, 2, or any of the myriad of presentations, we really do have to consider the potential for adverse drug reactions from the medications that we prescribe. Traditional atypical antipsychotics, particularly second-generation, do have a high risk of metabolic side effect. Many of these medications increase insulin resistance, cause increased appetite, which results in weight gain. It can have the potential to affect their circulatory system and their blood pressure and things like that. When you're looking at a patient like this one in the example that already has an established history of diabetes, hypertension, and high cholesterol, you're already kind of pushing out many of the atypical antipsychotics that could potentially be effective for this patient simply because they have the risk to increase these particular issues for this patient. This patient has been well maintained for her diabetes, her hypertension, and her cholesterol issues with the medications that she's been taking for well over 10 years in most cases. You want to make sure that you're selecting a medication that is not going to exacerbate those particular symptoms and make them worse. Again, when you're looking at atypical antipsychotics, especially considering monotherapy, you're going to choose something that has a much cleaner metabolic profile so that you're not potentially causing more complications for the patient.

A psychiatric mental health nurse practitioner shares her approach to treating bipolar 1 disorder and considers the role of comorbidities in shaping treatment selection for patients.

Pharmacological Treatment Considerations for Bipolar Disorder

 Our case presentation today focuses on a 75-year-old female patient who has had a long history of bipolar 1 disorder for about 40 years recently referred for consultation by a fellow psychiatrist at the nursing home due to persistent depressive symptoms. For the last 40 years, she's been effectively maintained on lithium with the dose only recently increased to help with her reported depression. She suffered from a significant tremor as well as some polyuria polydipsia, which then again aggravated her propensity for UTIs [urinary tract infections]. Historically, her lithium levels were stable in the low normal range around 0.6 mEq/L but recently increased about a month ago with the dose increase and an attempt to treat her depressive episodes. Her current lithium level is about 1 mEq/L. Her lithium dosage was decreased to achieve the prior stable level of 0.6 before she came to us. Lithium was then augmented with a little Lamictal or lamotrigine, which was then slowly titrated to 300 mg per day, but unfortunately, she failed to improve. Most recently, she underwent a trial of lurasidone 20 mg every evening with supper, but after about 7 days, she could not tolerate the nausea so then it was discontinued. She has historic diagnosis of diabetes Type 2 for about 30 years. She's being currently treated with Metformin 1000 mg a day and Invokana 300 mg a day. Hypertension for about the last 10 years effectively managed with olmesartan 40 mg a day. High cholesterol for about 40 years, effectively managed with rosuvastatin 40 mg a day and then also a history of frequent and recurrent urinary tract infections, about 5 years ongoing and effectively treated with nitrofurantoin 100 mg or other antibiotics when indicated.

Sadly, this presentation is quite common. As people age, our bodies process medications, and medications that have worked for long periods of time sometimes lose their efficacy as we age. Mostly due to those pharmacodynamic changes where our bodies age, our kidneys and our liver don't just quite function the way they did when we were younger and process things out. There's always a concern when you're using multiple medications on someone in this age range, just for interactions. Most notably in a review of the medications, Invokana itself actually can increase the incidence of polyuria and polydipsia and does have a potential side effect of an increase in urinary tract infections. As a provider, I do have some concerns about that particular medication being on board. Regarding her presentation, the onset of depressive symptoms, especially for a patient who might be within an assisted living facility, this is kind of common. Patients who live in assisted living facilities tend to get distanced from their families and don't have quite as much daily interaction and so an increase in depressive symptoms is quite common. Unfortunately, she's been maintained very well on lithium for quite a long time. It looks like even with the dose adjustment she was doing OK, but the addition of the lamotrigine really didn't help her depression so now we have concerns of what can we add on or what can we take away to help improve her overall outlook? Again, one of those concerns is that she's already got several medications onboard and the risk for polypharmacy among the elderly is always very high, including the potentiated risks of the medications interacting with each other.

Bethanie Simmons-Becil, DNP, MSN, APRN, PMHNP-BC, APHN-BC, presents the case of a 75-year-old female with bipolar 1 disorder and discusses challenges in bipolar disorder treatment.

Bethanie Simmons-Becil, DNP, MSN, APRN, PMHNP-BC, APHN-BC

Articles

Unmet Needs in Bipolar Disorder Management

Role of Patient Education for Bipolar 1 Disorder Treatment

Pharmacological Treatment Considerations for Bipolar Disorder

Patient Case: 75-Year-Old Female With Bipolar 1 Disorder