COVID-19 Pandemic’s Effects on Assessment & Psychopharmacological Management

BIPOLAR UPDATE

Literature is emerging on the effects of the coronavirus disease 2019 (COVID-19) pandemic on patients with bipolar disorder. This is part of the much larger literature on assessment and management of mental disorders during the pandemic.¹

Our group of 11 clinicians at the US Department of Veterans Affairs Bipolar Disorders Telehealth Program recently published a summary of lessons learned from using telehealth modalities (videoconferencing and telephone contact) with more than 3000 veterans whose caregivers submitted consultation requests.² Telemedicine is the way many, if not most, patients currently are being seen by clinicians. Many patients will continue to use this method even after the pandemic has waned. Telehealth has some specific effects on patients with bipolar disorder.

Video sessions and calls generally are very much welcomed by patients who are isolated to various degrees because of COVID-19. Their usual social outlets are diminished, and their access to in-person visits with clinicians is much reduced or eliminated. Hence, contact with an upbeat, thorough, authoritative, and supportive consulting clinician can have a tremendous effect in reassuring patients that help is available. In fact, symptoms may diminish immediately during the call.³

Effort must be made, however, to deal effectively with wireless connectivity issues that may render speech garbled with dropped words or pronunciations that are difficult to understand.² It is important to slow down the conversation, adjust volume or microphone or video placement, be mindful of the time lag that can occur between speech and the transmission of the speech, and avoid interrupting the patient by responding too quickly. Video and phone transmission might make it difficult to determine if the patient is becoming tearful or agitated, and it is important to ask if this is occurring.

Another issue associated with the pandemic is the loss of usual routines of behavior associated with previous mood states before isolation can result in new outlets (eg, buying online instead of in stores during manias). The clinician should be prepared to ask questions to uncover new syndromic behaviors.

Bipolar psychopharmacology issues that are relatively unique to the COVID-19 era were summarized in a recent review by experts from Spain.⁴ Medication adherence is often reduced during isolation, so it is important (after establishing a therapeutic alliance using some of the previously noted suggestions) to inquire about adherence. Similarly, after examining the possible causes of nonadherence (eg, real or feared adverse effects, the feeling of being controlled by the medication, missing periods of euphoria), clinicians should educate their patients about the importance of adherence. Help may be needed from significant others in the household to monitor adherence, with the patient’s permission.

Substance use disorders may increase in severity in the isolation setting, and these should be ruled out or managed, if necessary. Patients may be fearful of initiating new medications without an in-person encounter, especially if bloodwork is required or patients have concerns about entering a medical facility for testing.¹ The importance of lithium levels and kidney function tests will need to be reiterated and the benefits weighed against the risks associated with going to get the tests, which can be minimized with appropriate social distancing and masks.

There are some issues to consider with medications used in the treatment of patients who have COVID-19, if the patient requires hospital treatment.⁴ Dexamethasone can induce mood switches to mania or depression. Dexamethasone’s metabolism is induced by carbamazepine and, to a lesser extent, by oxcarbazepine. Initiation of these anticonvulsant mood stabilizers should therefore be avoided if possible. They also induce the metabolism of remdesivir, and carbamazepine may add to the risk of liver dysfunction caused by this antiviral agent. If the patient is already on one of these mood stabilizers, appropriate dosage adjustments of the COVID-19 drugs and lab monitoring will be needed. Chloroquine and hydroxychloroquine should be avoided in patients with COVID-19 and bipolar disorder because they increase risk of mania, psychosis, and suicidal ideation.⁴

Dr Osser is associate professor of psychiatry, Harvard Medical School, and co-lead psychiatrist at the US Department of Veterans Affairs, National Telemental Health Center, Bipolar Disorders Telehealth Program, Brockton, Massachusetts.

References

1. Bojdani E, Rajagopalan A, Chen A, et al. COVID-19 pandemic: impact on psychiatric care in the United States. Psychiatry Res. 2020; 289:113069.

2. Burgess C, Miller CJ, Franz A, Abel EA, et al. Practical lessons learned for assessing and treating bipolar disorder via telehealth modalities during the COVID-19 pandemic. Bipolar Disord. 2020;22(6):556-557.

3. Brown WA. The Placebo Effect in Clinical Practice. Oxford University Press; 2013.

4. Hernández-Gómez A, Andrade-González N, Lahera G, Vieta E. Recommendations for the care of patients with bipolar disorder during the COVID-19 pandemic. J Affect Disord. 2021;279:117-121. ❒