Patient centricity in psychiatric management: Bipolar I
Managing bipolar I disorder (BD-I) is a long-term commitment, and factors such as symptoms and side effects influence treatment planning. While switching medications may sometimes be necessary, frequent switches can also disrupt care and strain therapeutic engagement.
To find out more, pharmaphorum spoke with neuropsychiatric physician assistant Rebecca Barbee, of PA-C, Southlake Psychiatry, for a conversation exploring how medication switching shapes the treatment journey for patients with BD-I and what clinicians can do to foster more sustainable, patient-centred care.
Q. From your clinical experience, how does frequent medication switching shape the overall treatment journey for people living with BD-I?
Rebecca Barbee: Medication switching is a double-edged sword. Bipolar I disorder is a lifelong illness, with outcomes shaped by many variable factors, any one or a combination of which could necessitate medication changes. BD-I presenting in a person’s late teens or early 20s can look very different than it does in their 40s, 50s, or 60s. As a result, it’s appropriate that treatment planning evolves accordingly. However, if we’re frequently changing medications or making “tweaks” to dosing, it can set an underlying tone that medication is the only way we support bipolar disorder, inadvertently minimising the psychosocial factors that are also essential to treatment.
There is also fear associated with medication switches. Conditions as complex as BD-I require a therapeutic balance, and introducing new medications, even when clearly clinically indicated, can heighten risk for decompensation and instability of mood. We see this reflected in national data as well. In a Harris Poll survey, healthcare providers reported that their patients with BD-I switched medications an average of seven times during their lifetime and 77% agreed that frequent switching is detrimental to patients’ quality of life.
Providers need to be intentional about having conversations with patients about expectations. Without that transparency, there may be a disconnect between what patients expect a medication to achieve and what their provider expects. Within those discussions, it is important that we are always selecting medications supported by evidence-based data for their use in that specific presentation. Really honing in on diagnostic clarity and personalised medicine is key, so that we’re choosing the most appropriate medication and not constantly cycling through changes.
Q. What are the most common reasons patients tell you they want to change or stop a medication?
In that same Harris Poll survey, healthcare providers reported that the most common reasons their patients switch medications are feeling their treatment is not effective (82%) and side effects are intolerable (81%). That very much reflects what I see in clinical practice. The most common reasons patients tell me they want to change or stop a medication are adverse effects and tolerability.
Ideally, before we ever initiate a medication, there needs to be a very clear discussion about potential side effects and which of those are a no-go for the patient versus which ones they may be willing to adjust treatment around if needed. These conversations are about presenting risks and benefits side by side. Everyone responds differently to a given medication, and my objective is to consider the value of both efficacy and quality of life.
Q. What warning signs tell you that a patient may be struggling with their current treatment, but hasn’t yet said so directly?
To me, the biggest warning sign is the frequency of appointments. Sometimes patients will increase how often they’re scheduling because they’re struggling and that can be a clue that their current treatment plan isn’t working even if they haven’t said it directly. On the opposite end, patients who become lost to follow-up can indicate lost faith in the medication regimen or that they're having problems with their treatment.
In collaborative treatment planning, a person living with BD-I and I will come to the same conversation with different experiences, observations, awareness, and objectives. The patient-provider relationship is important so that, at the end of that conversation and going forward, we can be aligned in our plan and why. Looking at patterns like appointment frequency, outreach through the portal or phone calls, and changes in engagement can be some of the earliest indicators that something isn’t right. When I have established trust with a person, it makes it easier to identify what may be affecting their care or wellbeing and how to help.
Q. Why do some patients hesitate to raise concerns about their medication with their provider and how can clinicians actively lower those barriers?
Patients tell me that one of the biggest reasons they hesitate to raise concerns is that they don’t want to bother or annoy their provider. I remind them that this is my job and a duty I value and take seriously. There can also be a hesitancy to feel judged, depending on how communication has gone in the past. Practical barriers play a role as well. In my office, for example, patients have to call for an appointment, rather than use an online portal, and for some people even picking up the phone can be a barrier. Depending on the severity of their illness and their level of insight into their condition, they may not even recognise that something isn’t working as intended with their medication. And, of course, there are real-world concerns like, “Can I afford care?”, “Can I get an appointment?”, or “Can I access the treatment I’ve been prescribed?”
To actively lower those barriers, clinicians need to make sure there are appropriate systems and processes in place to support patients between visits, whether that’s messaging, phone calls, or another way for patients to reach out. Establishing rapport is also part of our responsibility as clinicians. We have an obligation to provide a safe and open space, to be non-judgemental and to listen, to be able to say to a patient, “Call me if something doesn’t feel right.” Asking simple, open-ended questions can also foster more honest conversations, such as: “How is your treatment plan working for you?”, “Have you had to stop or skip doses for any reason?”, and “How are you feeling day-to-day?”
Those questions create room for patients to talk about side effects, expectations, and how treatment fits into their daily lives, which is where many concerns first show up.
Q. How can patients prepare for appointments so conversations about treatment goals are more productive?
To begin with, it is helpful when patients know the names and doses of all the medications and over-the-counter products they’re taking, and the names of each of their providers and how to reach them, because communication between providers and across specialties is critical and often challenging.
My patients know that I love lists. Having a list of concerns that may have arisen between appointments helps us focus on what’s most important and to triage what needs to be addressed first, including setting a plan for follow-up visits. Putting some thought into questions or concerns ahead of time can contribute to more productive conversations because high-value topics aren’t accidentally skipped or forgotten and there is space for conversation.
Q. In your experience, what distinguishes treatment plans that patients stay with long-term from those that lead to repeated switching?
I think communication and education distinguish treatment plans that patients stay with long term. Patients deserve to understand why they’re taking a medication and why specific treatment recommendations are being made. That education benefits from being ongoing, because many times medications are initiated or changed during periods of crisis, and we can’t assume everything is fully processed or remembered from those moments. I value any moment when patients feel comfortable telling me that something doesn’t feel right or if they have concerns.
Treating any chronic disease has the potential to cause some type of downstream impact on a person’s physical wellbeing and lifestyle, whether that be side effects or simply having to remember to take a medication. However, most people are willing to tolerate some side effects relative to the benefit they also experience. When they understand the purpose of a specific medication and feel heard by their provider, they’re much more likely to stay engaged in their treatment over time.
This is why I put so much care into working with patients around medication choice, and considering both established and newer products that best meet a person’s needs. Having options to present when working with patients to plan a course of treatment is hugely beneficial. The longer a person is successfully on a consistent course of treatment, the more confidence we can all gain in their outcomes. This helps both me and my patients feel comfortable with and commit to the choices we’re making.
About the interviewee
Rebecca Barbee is a physician associate at Southlake Psychiatry in Davidson, NC. In this role, she is charged with diagnosing psychiatric disorders and implementing treatment plans; collaborating with colleagues to offer care management, patient education, and mental health services; implementing therapeutic regimens through direct patient care; educating patients on strategies to improve health; and staying abreast of advances in treatments and diagnostic tools. Barbee has over 13 years of clinical experience in psychiatry, with a well-developed skillset in patient assessment, psychopharmacology, addiction psychiatry, and child/adolescent/adult psychiatry. She is a member of the Association of PAs in Psychiatry, the American Academy of Physician Associates, and the North Carolina Academy of Physician Assistants. She has served as a faculty member and speaker at Psych Congress Elevate and Psych Congress. She serves on speaker bureaus for Neurocrine Biosciences, Axsome Therapeutics, and Alkermes. She has also served as advisory board participant for Supernus Pharmaceuticals and Axsome Therapeutics. Barbee has a passion to reduce the stigma around mental health and promotes increased access to mental health care and education of both clinicians and the general public.
