TCPR: I’d like to shift to a topic that psychiatrists probably don’t think about as much as we should, which is how we discuss our diagnostic impressions with our patients. How do you approach this in your work with bipolar disorder?
Dr. Baldassano: I do think it’s important in your diagnostic interview to save enough time for psychoeducation. If we did that, we would be more likely to have compliant patients, because they would understand the need for treatment. I will typically spend 15 to 20 minutes explaining to my new patients what I believe their diagnosis to be. I’ll come right out and say, “I think you have bipolar disorder.” You look at their reaction. Sometimes they are obviously uncomfortable with the diagnosis, and sometimes they might disagree. I’ll say, “This is why I think you have it,” and go through my thought process. If I sense it’s a difficult diagnosis for them to accept, I’ll soften the blow by saying something such as, “There are two major types of depression—unipolar depression and bipolar depression. You suffer from bipolar depression.”
TCPR: Are there other things you discuss with patients?’
Dr. Baldassano: I also talk to patients about the prognosis and treatment course, saying something such as: “Bipolar disorder is lifelong, we don’t cure it, but we have medications that can help treat it and our goal is to extend your period of wellness as long as we can.” I’ll often use the analogy of diabetes, and it’s an analogy that works well, because bipolar disorder, like diabetes, is lifelong. You probably have to stay on medication, but it’s not enough to just take meds—you have to eat right, get exercise, check your blood glucose. In both illnesses, you have to be an active participant in your care by adhering to a routine and structure. For bipolar, I talk about the importance of mood charting, being aware of what triggers your mood episodes, knowing that early identification of episodes tends to help treatment. And I give them handouts and recommend two books in particular, one is Take Charge of Bipolar Disorder (Fast JA, Preston J. New York: Warner Wellness; 2006), and the other is a cognitive therapy workbook titled Managing Bipolar Disorder: A Cognitive Behavior Treatment Program Workbook (Otto MW, Reilly-Harrington NA, Kogan JN, Henin A, Knauz RO, Sachs GS. New York: Oxford University Press; 2009).
TCPR: I thought we might wrap up by talking about ways that we non-specialists can improve. What are one or two of the biggest improvements you’d like to see in the way referring clinicians practice?
Dr. Baldassano: One of the things I see is that patients often come to me on very complex regimens of too many medications.
We tend to be good at adding medications, but not good at taking away meds. We as a field need to get better at evaluating how a patient is responding to a course of medications, and if they are not responding, we need to be willing to discontinue some of them. And related to that, we need to do a better job of ascertaining whether patients are taking their medications at all. In my interviews, I usually ask patients if they are taking their medication, because unless you ask it, they won’t tell you. The other major thing I’ve seen is a reluctance to prescribe lithium, which can be very effective for patients in all phases of bipolar disorder. So often, I’ll do a four hour consultation for someone with treatment-resistant bipolar disorder only to find that they’ve never had a lithium trial, and are not doing well on the more modern and more expensive medications.
Dr. Baldassano’s Approach to Prescribing Lithium
TCPR: Well why don’t we help our readers learn more about lithium. You’ve prescribed it to hundreds of patients. Tell us how you prescribe it.
Dr. Baldassano: First, I prepare patients because many of them are scared of lithium and associate it with the severely mentally ill in state hospitals. I tell them it’s one of the gold standard treatments for bipolar; that it’s been around since 1970 and we have long clinical experience with it. I also say, “It is a natural element. You’ll find it on the periodic chart,” which helps defuse the fear of taking it to some extent. And then I prepare patients for the monitoring required: “This is a medication that requires a level of responsibility because there are certain precautions. For example, we’ll need to get blood levels, because it has a narrow therapeutic index, meaning that if it goes too high it can be dangerous, and if it goes too low it won’t be effective.” I also tell patients right away that they need to stay hydrated while taking it, and by that I don’t mean forcing down eight glasses of water a day. I mean if they are dehydrated for some reason, such as having the flu or running a marathon, they need to be especially aware of the need to drink. Finally, I make sure they tell their other doctors that they are taking it, because there are various drug interactions possible.
TCPR: And once you’ve laid this groundwork for your patients, what formulation do you use and how do you dose it?
Dr. Baldassano: I start by prescribing 300 mg immediate-release lithium taken at night. Data shows immediate-release at bedtime is better for kidney function, because the kidney likes having one peak level that goes down, rather than a constant level all day which results from controlled-release formulations. I instruct them to stay at 300 mg for five days, then take 600 mg for five days, then 900 mg. After at least five days on 900 mg, I have them go to the lab for a trough blood level, drawn 12 hours after the last dose. However, in geriatric patients I will have them stay at 600 mg and get that level.
TCPR: What baseline labs do you order, and do you make sure to see baseline labs before they take their first dose?
Dr. Baldassano: I order baseline tests to measure thyroid stimulating hormone (TSH), a blood urea nitrogen (BUN) test to see how well the kidney and liver are working, and a creatinine blood test. While textbooks will tell you to get labs before the patient starts taking lithium, in clinical practice this means you end up delaying the first dose, sometimes substantially. Meanwhile, your patient is suffering. So I don’t have patients wait, but I do impress upon them the importance of getting labs soon, within a week of starting the lithium.
TCPR: What kinds of issues do you see as patients are titrating their dose up?
Dr. Baldassano: The most common early side effects are gastrointestinal, such as nausea, queasiness, and cramping. I tell patients to stop increasing the dose if they experience these, and to wait until the symptoms go away before resuming the titration. Every once in a while, I will see a patient referred to me who is on an extended-release lithium who is having diarrhea, and an easy fix is to simply switch them to immediate-release once a day—this almost always works.
TCPR: How do you interpret lithium levels?
Dr. Baldassano: Before I evaluate the levels, I’ll always ask the patient “was this a 12-hour blood level?” because many times it isn’t a trough level and then the number is not useful. But I’m aiming for a lithium level of 0.8 or above, especially for bipolar depression, which, in my experience, tends to require higher blood levels for efficacy. I try not to go higher than 1.1 because most patients have side effects above that. If they are subtherapeutic, I will increase the dose, using the rule of thumb that every 300 mg addition leads to about a 0.2 increase in blood level in nongeriatric patients. Each time I increase the dose, I ask them to get another level after at least five days have passed. Generally I get patients therapeutic within a month using this procedure.
TCPR: What about follow-up labs after the level is therapeutic?
Dr. Baldassano: There are no official, specific guidelines on checking labs. I do another lithium level four to six weeks later, including a BUN, creatinine, and TSH. If they are new to lithium, I might check it one more time in eight weeks, and once I’ve established this person is doing well, and they have a consistent level, I may not check it again for six months. I usually check lithium twice a year, but in some very stable patients only once a year. Meanwhile, I’ll check BUN/creatinine at the same frequency I check lithium levels, and I check TSH less frequently, usually once a year. One important thing to know about the thyroid is that if you see TSH increasing, then you have a discussion with the patient. Because about 3% of patients will develop permanent hypothyroidism, and this is more common in women. It can be reversible, if it’s caught within six to eight months, but the patient has to stop the lithium.
TCPR: Thank you, Dr. Baldessano.