Dr Moukaddam shares factors to consider when approaching the treatment of bipolar disorder.
Nidal Moukaddam, MD, PhD: The art of psychiatry is making sure to look at the patient holistically and having a comprehensive history that then links to treatment, because you don’t want to ignore important things such as their medical history, metabolic profile, constraints on their job, and family history. Let me go into some of these. If you think that the treatment that they would benefit from is a pill that’s given 3 times a day, but their work does not allow them to do that, then you would not want to proceed because the patient would not be adherent. Similarly, financial considerations are very important. If I think a particular pill would be fantastic for the patient, but they cannot afford it for more than a month, then it would not be sustainable.
These would be your first considerations: Can they afford it, will it mesh with their schedule, and does it fit well with their medical profile? We have not talked about this patient’s medical history but somebody who has obesity, diabetes, or other conditions could not potentially take an agent that causes weight gain. Because even though the agent could be beneficial for psychiatric symptoms, the weight gain would be unacceptable and make the other conditions worse. Those are huge considerations: the metabolic profile and medical history. As mentioned in the case, this patient developed hyperthyroidism, so that’s one of the things we consider with lithium, especially long-term treatment.
The one other thing you discuss with the patient, which is really important, is that bipolar disorder doesn’t typically go away. You will have to be on medications for an extended period of time, perhaps for the rest of your life, so we really want to find a medication regimen that is comfortable for you. When I say treatment, treatment is not only medications. We have to consider whether there’s any therapy that could work. Psychotherapeutic modalities are extremely effective for certain things, especially for rhythm therapy and making sure people know how to manage their sleep and energy and how to catch symptoms before they start. Psychoeducation is your first step. You can do that in office, but therapy is often missed or underused, and I think that would be important for anybody making a treatment plan.
Transcript Edited for Clarity