Bipolar Disorder Treatment Challenges: Diagnoses, Comorbidities, and Polypharmacy

When treating depression in bipolar disorder, challenges can include inaccurate and delayed diagnoses, limited efficacy and speed of treatments, and the persistence of debilitating symptoms such as cognitive impairment and anhedonia. Additionally, treatments may often focus on symptom mitigation rather than restoring quality of life. Using his 25 years of experience as the head of a mood disorders psychopharmacology academic program, Roger McIntyre, MD, FRCPC, professor of psychiatry and pharmacology at the University of Toronto, offers insight into some of the challenges associated with diagnosing and treating bipolar disorder, comorbidities, and what payers need to understand about patients' polypharmacy needs. 

Answers have been lightly edited for clarity.

What are the most common challenges in treating patients with depression in bipolar disorder?

The most common challenges I have in treating depression in people with bipolar disorder are first, many—in fact, most—are not diagnosed accurately or timely. So diagnostic accuracy and timeliness are still a problem.

But within people who have the diagnosis, there's no doubt about it that the challenge is to have treatments that are reliably and robustly efficacious in a short period of time. In other words, most treatments we have are not reliably effective, not robust, and take far too long to work.

The other part which is related is when we get into the granularity of the symptoms, not all symptoms of depression are created equal. Some symptoms are much more disquieting to people with depression, and much more functionally impairing. For example, cognitive symptoms in depression, symptoms of anhedonia, or absence of pleasure, are persisting, often debilitating, and don't cooperate with many of the available treatments. So that's another part.

And then finally, function and quality of life. We have treatments that can mitigate symptoms, but we don't have treatments, necessarily, at least not as many as we would like, that can actually give people their life back. A sense of joie de vivre, a sense of feeling positive mental health vitality, a sense of getting back to the usual life trajectory.

So whether it's from a symptomatic perspective or a functional quality of life perspective, there are many unmet needs. But it comes back to this first point: the diagnosis not being timely or accurate, and having treatments that are reliably, robustly, and quickly efficacious.

What should payers understand about this patient population?

By its very definition, bipolar disorder is a chronic illness. Secondly, people with bipolar disorder, in part because of the complexity, are often prescribed multiple medications over the long-term course.

In other words, if we define polypharmacy as 3 or more psychiatric medications, that's reached and exceeded by at least half of people with bipolar disorder. These polypharmacy regimens are renewed for many years. And that's just the psychiatric medication. That doesn't include other types of medication, for example, for blood pressure, heart disease, thyroid, the list goes on. So polypharmacy is the rule, not the exception.

The related issue I'm going to bring up is comorbidity. There's no mental disorder in all of psychiatry that has more concurrent psychiatric and medical problems than bipolar disorder.

So payers will see people who are prescribed polypharmacy, and then when you look at the diagnostic coding, these individuals will have not only a diagnosis of bipolar I disorder, but they will also have additional diagnoses. Anxiety disorders, ADHD, eating disorders, alcohol substance use disorders, obesity, diabetes, heart disease, migraine, on and on.

Going back to that statistic about polypharmacy, a similar statistic exists for polymorbidity. About half our patients have 3 or more conditions. So again, for payers, they're going to see this. They see this in their databases, their utilization data, that these individuals have high rates of polymorbidity, polypharmacy, and chronic drug exposure.

Is there anything else you would like to add today that we haven't discussed yet?

We do know, and this is relevant to payers, the most common reason for premature death in bipolar disorders is cardiovascular disease. So these concurrent conditions in bipolar disorder are not just an academic statistic. They are relevant to the lethality of the illness.

The age of onset of cardiovascular and other age-related disorders is much earlier in life. As we get older, we tend to accrue many types of disorders—arthritis, diabetes, heart disease. These conditions have their onset much earlier in life. And I think payers would likely encounter people who are being diagnosed and treated for these conditions years earlier than others in the general population.

This interview was originally published in Veterans Health Today.

Roger McIntyre, MD, FRCPC, is a professor of psychiatry and pharmacology at the University of Toronto and heads up the Mood Disorders Psychopharmacology Unit in the University Health Network in Toronto.