The critical role pharmacists play in continuity of care for bipolar I disorder
In any clinical context, continuity of care is an important contributor to long-term outcomes. Treating serious mental illnesses, such as bipolar I disorder (BD-I), benefits from a personalised and longitudinal approach. However, the reality of managing BD-I is that consistency can be challenging to achieve.
One recommended approach to enhancing continuity in BD-I treatment is to deploy coordinated care teams. Establishing protocols that facilitate communication across healthcare providers, including clinicians, therapists, and pharmacists, and embracing each professional’s unique expertise can enhance patient engagement and wellbeing.
The complexity of treating and managing BD-I
The nature and nuance of BD-I demand a thoughtful approach to treatment planning. Those living with BD-I cycle between depression and elevated mood states (termed either mania or hypomania). Treatment, including use of approved medications, is intended to limit the severity and frequency of those extremes. However, even when medication is effectively managing symptoms, the variability inherent in the condition, as well as everyday life, can impact both mood and treatment engagement.
During depressive phases, patients often have less energy and ability to engage with day-to-day routines. Appointments may be missed, meaning questions go unasked and behavioural shifts unobserved. Medications are still prescribed appropriately, but patients may lack the structure or motivation to continue with recommended plans.
When mood shifts toward mania or hypomania, barriers to continuity change. Patients may feel extremely capable, productive, and energetic, causing the urgency to stay engaged with ongoing care to fade. Medications that modify the intensity of these sensations may feel misaligned with how patients see themselves in that moment, even when clinically necessary for their safety and wellbeing.
Moreover, BD-I presents differently for each person and even differently from one moment to the next. As symptoms change over time, patients' needs will also evolve. Decisions made during a provider visit don’t always translate cleanly once a patient leaves that setting and is dependent on factors like their personal support system.
Medication effects can further complicate continuity over time. In my experience, patients taking medication to treat their BD-I often raise concerns about medication-related side effects, including weight gain, sedation, or emotional blunting. These side effects don’t always prompt immediate discontinuation, but they do influence how patients feel about staying engaged with treatment long term, particularly between visits when communication with the care team can be limited.
Decentralisation across systems and settings disrupts care
Treatment for BD-I is rarely linear. Mental healthcare occurs across many different settings of care that aren’t always well connected, including inpatient units, outpatient clinics, pharmacies, therapists’ offices, and even in the home and community. Someone living with BD-I may start or change treatment while hospitalised for an acute episode, continue following discharge with outpatient visits, and also manage their own day-to-day care at home. These settings operate with different systems and workflows and limited visibility into what is happening elsewhere.
Each transition introduces the potential for disruption. From my perspective as a health system-affiliated pharmacist who also works in community-based clinics, it’s that movement and what happens between touchpoints where many of the real challenges begin. Information does not always travel with the patient, and communication between providers across settings is often limited or delayed.
Plans made in one context don’t always translate cleanly to the next. Medications that worked in an inpatient environment may feel very different once a patient is back to their regular routine. Maybe the medication doesn’t feel right, or the dosing schedule doesn’t fit into daily life. Questions emerge or side effects show up days or weeks later. In between appointments, there are long intervals during which patients are trying to live their lives. Electronic health records can’t capture a patient’s lived experience of treatment once they leave a clinical setting.
Over time, uncertainty builds and those challenges can accumulate, making it harder to carry a treatment plan forward. Care remains technically in place, but continuity weakens. Plans become harder to sustain and follow-up becomes reactive, rather than ongoing.
Where pharmacists naturally fit
Pharmacists are uniquely positioned within the broader mental healthcare delivery system because they are one of the most accessible healthcare professionals. Patients don’t have to wait weeks to ask a question or raise a concern. Instead, these conversations can take place when patients come to the pharmacy to pick up their prescription, whether it’s the first fill or a refill.
On the first fill, pharmacists can walk through the medication in detail. What exactly it is prescribed to help with. What to expect, including possible side effects. What to watch for that may warrant reaching out with questions. When patients come back for refills, the conversation shifts. These subsequent visits become an opportunity to talk about how the medication is working, what the patient is feeling, and if there are any concerns. This level of engagement isn’t always possible in a brief office visit, even when prescribers are doing their best with limited time.
Pharmacists often see adherence through the patient’s lived experience with the medication. In my experience, patients seek out a pharmacist’s perspective when they’re experiencing some impact to their lives, potentially a side effect or another concern or question about the medication. They ask whether this is something they’ll need to be on long-term. They ask about insurance changes and coverage. They might ask about another medicine they receive, which facilitates dialogue about possible interactions or polypharmacy.
Each of these moments is an opportunity for conversations that don’t always happen elsewhere. The fact that these questions surface at the pharmacy reflects the reality of how people interact with care systems, how complex psychiatric treatment is, and how limited time can be in traditional clinical visits.
Transitions of care are when continuity is most vulnerable
Transitions of care – in particular around hospital discharge, when people move back to their community and outpatient care – are when treatment continuity most often breaks down. Patients are often released with prescriptions for the medications they need, but without medication in hand. Subsequently, they may encounter insurance issues, such as required prior authorisations or needing a medication that isn’t covered. Sometimes they leave an inpatient stay on duplicate therapies or regimens that don’t translate well to the outpatient setting. These are the kinds of issues pharmacists tend to observe and are equipped to help address.
Transitions are also when medication effects begin to interfere with daily routines. For example, a patient may be discharged on a new mood-stabilising regimen that was appropriate in the inpatient setting, only to experience sedation once they attempt to return to work. These concerns often surface at the pharmacy before the next psychiatric follow-up, when patients are deciding whether the treatment is sustainable.
When pharmacists are part of the care team, formulary issues, access issues, and medication duplication or interactions can be addressed before they lead to destabilisation or subsequent hospitalisation. This early intervention matters, especially in BD-I, where repeated hospitalisations can erode a patient’s baseline wellbeing over time. Each breach in treatment increases the risk of relapse, emergency department visits, and inpatient stays. From the patient’s perspective, these disruptions can be destabilising and exhausting. From a care perspective, many are preventable.
Pharmacists are positioned to support patients through this by filling in the gaps that naturally exist between visits, settings, and transitions.
Treatment planning matters for continuity of care
BD-I is clinically complex to manage, and patients and providers should work together to find the treatment that works for them. This is another instance when having the pharmacist’s perspective over the course of a person’s treatment journey is valuable.
Maintaining continuity with prescribed medications is partially influenced by how tolerable a treatment is in daily life. Patients are more likely to remain engaged when side effects are manageable and expectations are clear. Pharmacists’ knowledge about how various medicines work, potential drug-drug interactions, and patients’ medication histories are all relevant to treatment planning.
In BD-I, newer treatment approaches have increasingly focused on long-term tolerability as a core component of continuity of care, alongside clinical effectiveness. This includes thoughtful medication selection, ongoing monitoring, and use of therapies designed to address side effects that have historically contributed to disengagement. For example, medications such as LYBALVI (olanzapine and samidorphan) were developed as part of these efforts, with the aim of mitigating metabolic side effects historically associated with certain antipsychotic therapies. These are meaningful considerations for patients managing a chronic condition and navigating long-term treatment decisions.
When pharmacists are integrated more intentionally into care, patients benefit from early support and ongoing education. Through cohesive communication with pharmacists, prescribers can gain insight into how treatments are working outside the clinic. When this is done well, continuity becomes something that is maintained over time, rather than rebuilt after each crisis.
BD-I is a lifelong condition, so treatment is about managing symptoms over time, across settings, and through inevitable changes. Oftentimes, pharmacists will have a role in supporting a patient through these changes. Recognising their critical role in continuity of care is an acknowledgment of where care already lives.
About the author
Dr Alberto Augsten is founder and director of the Long-Acting Therapy (LAT) Clinic at Memorial Regional Hospital in South Florida. His career spans clinical toxicology and psychopharmacology, specialised programmes, and healthcare innovation. Dr Augsten is also the driving force behind the Mothers in Recovery (MIR) programme at Memorial Healthcare System, supporting pregnant women and new mothers struggling with substance use disorders. He earned his Master's in Pharmaceutical Sciences with a concentration in Clinical Toxicology from the University of Florida and further solidified his expertise by becoming a Diplomate of the American Board of Applied Toxicology (DABAT), specialising in clinical toxicology. With this background, he has provided expert witness testimony as a forensic toxicology expert in legal cases.
