Dr Roger Rivera on Collaborative, Individualized Care for Bipolar I Disorder

In recognition of World Bipolar Day, March 30, Roger Rivera, DNP, board certified as a family nurse practitioner (FNP) and psychiatric–mental health nurse practitioner (PMHNP), Mente Suave Psychiatry, and educator at the University of Florida, shared his insight with The American Journal of Managed Care® (AJMC®) in an email interview discussing collaborative, individually focused approaches to care and advancements in treatment for bipolar I disorder.

In this interview, Rivera discussed integrating psychotherapeutic techniques and medication regimens for bipolar disorder.

Roger Rivera, DNP

AJMC: How do you approach the integration of psychotherapeutic techniques to bolster coping skills and resilience against mood fluctuations in bipolar disorder treatment?

Rivera: As a clinician practicing in both community and private settings, I approach the integration of psychotherapeutic techniques with a deep understanding of the unique challenges posed by bipolar disorder. It is imperative to first assess where patients are on the rollercoaster of bipolar disorder, as therapeutic engagement can be more challenging during manic or hypomanic episodes. In such cases, it is often wise to initiate psychotherapeutic measures when a client is stabilized or in the process of stabilization to ensure effective engagement.

From a psychiatric perspective, providing detailed insights into this process involves utilizing all available resources to support patients in finding appropriate therapists and facilitating engagement. This may include collaborating closely with mental health professionals, such as psychologists or social workers, who specialize in bipolar disorder treatment. Additionally, educating patients and their families about the importance of psychotherapy, addressing any concerns or misconceptions they may have, and emphasizing the potential benefits of therapy in managing symptoms and enhancing overall well-being are crucial steps. Moreover, connecting patients with support groups, peer networks, and online resources can further enhance their readiness and motivation to engage in therapy.

The goal is to create a supportive and conducive environment that empowers individuals with bipolar disorder to actively participate in their treatment journey. By addressing barriers to engagement, providing tailored recommendations, and fostering collaborative relationships between patients and therapists, we can optimize the effectiveness of psychotherapeutic interventions and promote better outcomes for this patient population.

AJMC: Could you explain how long-term medication regimens can alleviate severe or recurrent symptoms, stabilize mood, and prevent relapse in bipolar disorder?

Rivera: In clinical practice, I prioritize a thorough understanding of the molecular structures and mechanisms of action underlying pharmacological interventions for bipolar disorder. When selecting long-term treatment modalities, it is essential to consider not only the clinical efficacy but also the pharmacodynamic and pharmacokinetic properties of the medications. By delving into the intricacies of how these molecules interact with the brain's neurotransmitter systems, we can gain valuable insights into their therapeutic potential and, in turn, create a uniquely tailored psychopharmacological approach.

For patients with bipolar disorder, finding a medication that targets key neurotransmitter pathways implicated in mood regulation is paramount. By modulating neurotransmitter activity, particularly dopamine, serotonin, and norepinephrine, these medications can help restore neurochemical balance and stabilize mood. Additionally, medications that exhibit both agonist and antagonist properties at specific receptor sites offer a nuanced approach to symptom management, providing both mood-stabilizing and antidepressant effects.

Furthermore, considering the bidirectional nature of bipolar disorder, where patients may experience fluctuations between manic and depressive episodes, it is crucial to choose medications with a balanced profile of efficacy and tolerability. By leveraging our understanding of molecular structures and mechanisms of action, we can tailor treatment regimens to address the unique needs and symptomatology of each individual.

While polypharmacy may be common in the treatment of bipolar disorder, the main goal is to achieve symptom control and long-term stability with the fewest medications possible. By harnessing the therapeutic potential of medications with favorable molecular profiles and mechanisms of action, we can mitigate symptoms and improve the overall quality of life for patients with bipolar disorder.

In summary, a comprehensive understanding of molecular structures and mechanisms of action informs our approach to pharmacological interventions for bipolar disorder, allowing us to select a treatment that offers optimal efficacy, tolerability, and safety profiles for our patients.

AJMC: When determining the appropriate psychopharmacological regimen for a patient, what factors do you take into consideration, and how do you ensure it is individualized?

Rivera: Determining the appropriate psychopharmacological regimen for patients with bipolar disorder involves a comprehensive and meticulous approach akin to that of an archaeologist, digging up clues, examining family history, assessing severity, and analyzing treatment responses. Each patient presents with a unique constellation of symptoms, treatment history, and personal circumstances, requiring a nuanced understanding and individualized treatment plan.

In evaluating symptomatology, it is essential to recognize the presence of mixed features, which can manifest as a blend of manic and depressive symptoms along with additional features such as anxious distress, inattention, and aggression.

Additionally, family history and treatment responses provide valuable insights into genetic predispositions and individual treatment trajectories, guiding the selection of pharmacological interventions. By carefully weighing the benefits and risks of available options, including novel treatments like [olanzapine and samidorphan], we can maximize therapeutic outcomes while minimizing adverse effects.

The goal is to select the most effective options at our disposal, drawing upon a combination of clinical expertise, evidence-based practices, and patient-centered care. By adopting an archaeologist's mindset and meticulously piecing together the puzzle of each patient's unique presentation, we can unearth the most promising treatment pathways and pave the way toward improved quality of life and long-term stability.

AJMC: Can you explain how evidence-based therapies like CBT and DBT facilitate skill development and challenge maladaptive thoughts in bipolar disorder treatment?

Rivera: Cognitive-behavioral therapy (CBT) and dialectical behavior therapy (DBT) are evidence-based therapeutic approaches that play a pivotal role in addressing the multifaceted nature of bipolar disorder. These therapies offer valuable tools for patients to manage mood fluctuations, regulate emotions, and challenge maladaptive thought patterns, promoting stability and well-being.

Cognitive-Behavioral Therapy (CBT):

Skill Development: CBT focuses on identifying and modifying maladaptive cognitive patterns and behaviors that contribute to mood instability in bipolar disorder. Through coordinated interventions such as cognitive restructuring and behavioral activation, patients learn to recognize and challenge distorted thinking patterns associated with mood episodes. By developing coping skills and problem-solving strategies, patients acquire the tools to effectively manage stressors and regulate their emotions.

Chemical Imbalance: From a neurobiological perspective, CBT can help address chemical imbalances associated with bipolar disorder by promoting neuroplasticity and modulating neurotransmitter activity. By challenging negative thought patterns and implementing adaptive coping strategies, CBT can influence neurochemical pathways involved in mood regulation, leading to favorable changes in brain function and chemistry over time.

Dialectical Behavior Therapy (DBT):

Skill Development: DBT combines cognitive-behavioral techniques with mindfulness-based practices to help patients regulate emotions and improve interpersonal relationships. Through skills training modules focused on distress tolerance, emotion regulation, mindfulness, and interpersonal effectiveness, patients learn to manage intense emotions and interpersonal conflicts more effectively.

Chemical Imbalance: DBT targets the chemical imbalances associated with bipolar disorder by promoting emotion regulation and reducing emotional reactivity. By cultivating mindfulness and acceptance of emotions, DBT can modulate neurotransmitter activity in brain regions implicated in emotion processing and regulation. Additionally, DBT emphasizes the importance of behavioral reinforcement and validation, which can contribute to the release of neurochemicals associated with reward and positive affect.

Engaging in CBT and DBT when patients are not in a debilitated manic state allows for the integration of these therapeutic approaches into their treatment plan, promoting skill development and habit formation. By applying learned processes during periods of stability, patients can reinforce adaptive coping strategies and establish routines that support long-term stability and wellness. These evidence-based therapies provide patients with the tools and strategies needed to navigate the challenges of bipolar disorder, promoting symptom management and improving overall quality of life.