Bipolar I disorder is one of the most intractable challenges in healthcare that can be difficult to treat.1 According to the National Depressive and Manic-Depressive Association (DMDA), 70% of patients with bipolar disorder receive an initial misdiagnosis and one-third remain misdiagnosed for ten or more years. But patients and caregivers alone don’t carry the weight of the Bipolar I burden. A Global Burden of Disease study reported significant strain on health systems as well. A recent US study published in the Annals of General Psychiatry found the economic burden of bipolar disorder to be over $200 billion annually.2,3
Roger Rivera, a Nurse Practitioner who treats patients with bipolar I disorder, says healthcare providers (HCPs) and systems have a responsibility to help patients receive earlier diagnoses and access to treatment options. In fact, the American Psychiatric Association found earlier diagnosis and treatment are one of the key factors affecting outcomes.
He believes this can be done by embracing a variety of treatment options, working with patients and their support systems to identify what works for them and what doesn’t, and then making appropriate changes to the treatment plan. Rivera says trial and error is often necessary to balance symptom control and side effects; otherwise, you risk patients not taking their medication as prescribed. A review conducted by Dr. Ibrahim Jawad found that 50% of patients living with bipolar I disorder do not take their medicine as prescribed (or are non-adherent)4, but Rivera believes that’s the wrong way to think about it.
“We have to stop talking about patients with serious mental illness as ‘non-adherent’ to their medications,” Rivera said. “That puts the blame on the patient. The reality is that many patients struggle with medications that may not adequately control their symptoms, come with intolerable side effects, or both. Why would anyone continue taking medication that isn’t helping or is actually having a negative impact on their quality of life?”
Rivera says that while side effects can seem like a secondary concern, it should be a key focus. While there are a variety of common side effects, the Mayo Clinic reports that significant weight gain is one of the most commonly reported side effects associated with bipolar I disorder medications.5 In an online survey, patients living with Bipolar Disorder identified the weight gained in the first three months of therapy as the side effect most likely to impact their adherence to bipolar medications.4
“I believe weight gain is important because it can impact the self-esteem of patients and may lead to metabolic disease. Some of my patients who have taken olanzapine in the past discontinued treatment due to this well-known side effect.”
In response to this issue, Rivera will often prescribe his appropriate patients LYBALVI® (olanzapine and samidorphan), which was approved in 2021.
LYBALVI is indicated for the treatment of adults with schizophrenia or bipolar I disorder for acute treatment of manic or mixed episodes as monotherapy and as adjunct to lithium or valproate or as a maintenance monotherapy treatment. It’s important to note that elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. LYBALVI is not approved for the treatment of patients with dementia-related psychosis.6
“If I have patients with bipolar who are not doing as well as they would like on their current medication, LYBALVI is another option I consider with them,” Rivera says. “In some patients for whom I have prescribed LYBALVI, including some who have tried olanzapine alone in the past, I have seen an improvement in their Bipolar I symptoms and less weight gain.”
Rivera stresses that no medication is right for everyone, but is glad he took the time to learn about LYBALVI and to prescribe it for appropriate patients.
“It’s a treatment option that HCPs can consider for patients living with Bipolar I,” Rivera said.
“I believe medication is an important part of the treatment journey. However, in my experience, medication alone cannot fully address patient needs. More focus should be placed on behavioral, psychological, and societal strategies. Once all aspects of the patient’s needs are addressed, a plan can be developed to effectively help them meet their goals.”
PARTNERING FOR BETTER OUTCOMES
In Rivera’s experience, patients who receive effective management can lower costs for healthcare systems because they are less prone to treatment discontinuation, hospitalization, or utilization of other healthcare resources.
As mental health treatment continues to evolve, different treatment options present opportunities to provide more options for patients. Continued education also can help facilitate earlier diagnosis, while providing new and more effective approaches to improving the patient experience. In Rivera’s opinion, this not only helps patients meet treatment goals; it also helps HCPs provide the best care and allows hospital systems to manage costs more efficiently.
References: 1. Bipolar Disorder. National Alliance on Mental Illness. https://nami.org/About-Mental-Illness/Mental-Health-Conditions/Bipolar-Disorder. Accessed April 25, 2023. 2. GBD 2019 Mental Disorders Collaborators. Global, regional, and national burden of 12 mental disorders in 204 countries and territories, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet Psychiatry. 2022;9(2):137-150. 3. Dembek C, Mackie D, Modi K,et al. The economic and humanistic burden of bipolar disorder in adults in the United States. Ann Gen Psychiatry. 2023;22(13):1-10. 4. Jawad I, Watson S, Haddad PM, et al. Medication nonadherence in bipolar disorder: a narrative review. Ther Adv Psychopharmacol. 2018;8(12):349-363. 5. Hall-Flavin DK. Bipolar medications and weight gain. Mayo Clinic. Accessed April 21, 2023. https://www.mayoclinic.org/diseases-conditions/bipolar-disorder/expert-answers/bipolar-medications-and-weight-gain/faq-20058043 6. LYBALVI® [prescribing information]. Waltham, MA: Alkermes, Inc.; 2021.
Roger Rivera, DNP, is a board-certified family nurse practitioner (FNP), psychiatric–mental health nurse practitioner (PMHNP) and Trauma Surgery first Assist. His areas of expertise include psychiatry, critical care, emergency medicine, and trauma surgery. He holds a Nurse Educator Certification from the University of Florida and is enthused with teaching the art and science of integrative psychiatric care, especially with the experience incurred in the various specialties.