Bipolar Disorder: Opportunity for Pharmacists to Improve Adherence and Health Outcomes

Bipolar disorder encompasses polarized depressive lows and manic highs, and is estimated to affect nearly 3 million individuals in the United States (US). Without proper treatment, the condition can lead to reckless behavior (involuntary hospitalizations, difficulties with the law, serious financial implications, or a person’s inability to manage self-care) and significant decline in social and occupational functioning.^1,2

As highly accessible health care professionals, pharmacists have the opportunity to improve medication adherence and health outcomes of patients with bipolar disorder.

There are 2 classifications of bipolar disorder. Bipolar I Disorder has an estimated 12-month prevalence of 0.6% in the US, whereas Bipolar II Disorder has a 12-month prevalence of 0.8%.¹ For a diagnosis of Bipolar I Disorder, the patient must meet criteria for a manic episode that is severe enough to cause marked impairment in social and occupational functioning. Diagnostic criteria for Bipolar II Disorder includes 1 or more episodes of hypomania with history of major depressive episodes.¹

First line therapy for patients with bipolar disorder typically consists of a mood stabilizer, such as lithium or valproate, and sometimes adjuvant or monotherapy with an atypical, or second generation, antipsychotic.² In most cases, antidepressants should be tapered and discontinued to avoid inducing a manic episode in bipolar patients. Prescribers must carefully consider adverse effect profile, patient’s medication history, and financial capabilities in selecting the proper medication regimen.

Comorbidities associated with bipolar disorder include anxiety disorders, conduct disorders, eating disorders, and alcohol or substance abuse. Additionally, the risk of suicide in bipolar disorder is 15 times greater than the general population, with up to one-third of patients with Bipolar II Disorder having attempted suicide.¹ With 20-60% of individuals reportedly not taking long-term prophylactic medications, risks associated with nonadherence to these medications include relapse, hospitalizations, suicide, and loss of productivity—all of which can accumulate a great cost in health care.^3,4

Understanding, anticipating, recognizing, and managing patient barriers is critical to improve medication adherence and therapeutic outcomes. Variables affecting medication adherence include fear of potential adverse effects, pill burden, poor access to care, length of illness, comorbidities, and unaffordable costs.⁴ Two decades of research recognize many determinants of nonadherence in bipolar patients, including the critical role of patients’ attitudes and beliefs regarding their medication, and the importance of collaboration among the health care team.⁵ While some of these variables are permanent, educating a patient about the importance of treatment, treatment expectations, and potential adverse effects can all contribute to better patient adherence and health outcomes.⁴

Many programs use medication adherence tools to improve outcomes in bipolar disorder. These include psychoeducational and family communication interventions, cognitive behavior therapy, and electronic adherence monitoring devices. Interventionists include pharmacists, psychologists, psychiatrists, nurses, and social workers. A recent systematic review found a significant effect using these interventions versus controls (Pooled OR 2.27, p < 0.001), and interventions focusing specifically on adherence had greater effect than combined adherence with mood management and lifestyle changes.³ Interventions addressing adherence may be more easily adapted to the health care setting, especially in community pharmacies.

Specific interventions addressing nonadherence include ensuring that a medication is more convenient to take. This includes manipulating how a drug may be packaged and delivered to help a patient remember to take the medication.⁴ Evidence has shown that simplifying a dosage regimen with pill boxes, medication organizers, blister packaging, or coordinating dosage times with activities of daily living, increases medication adherence.⁴ One study with twice-daily prompts by a personal assistant for patients to report behavior and symptoms led to improved adherence.⁶

Another study of pharmacy-based interventions, such as unit-dose packaging, educational sessions, refill reminders, and notifications to prescribers regarding patient nonadherence, showed improved adherence among patients who received the interventions.⁷ This demonstrates the impact that pharmacists can have on medication adherence. However, the implementation of such interventions may be a challenge in the current pharmacy workflow.

Treatment of bipolar disorder is very complex. Nonadherence can lead to many devastating outcomes including suicide, relapse, hospitalization, and worsening medical comorbidities—all of which contribute to avoidable health care costs. Effective treatment includes consideration of patient profiles and accommodation of patient preferences. Pharmacists can support prescribers and patients by providing adherence-directed interventions that lead to improved adherence, better health outcomes, and reduced health care costs.

References

• Ketter TA, Chang KD. Bipolar and related disorders. In: Hales RE, Yudofsky SC, Roberts LW, ed. The American Psychiatric Publishing Textbook of Psychiatry. Arlington, VA: APPi; 2014: 311-352.
• McCormic U, Murray B, McNew B. Diagnosis and treatment of patients with bipolar disorder: A review for advanced practice nurses. JAANP. 2015; 27:530-542. doi:10.1002/2327-6924.12275
• MacDonald L, Chapman S, Syrett M, et al. Improving medication adherence in bipolar disorder: A systematic review and meta-analysis of 30 years of intervention trials. JAD. 2016;194:202-221. doi:10.1016/j.jad.2016.01.002
• Levin JB, Krivenko A, Howland M, et al. Medication adherence in patients with bipolar disorder: a comprehensive review. CNS Drugs. 2016;30:819-35. doi:10.1007/s40263-016-0368-x
• Chakrabarti S. Treatment-adherence in bipolar disorder: A patient-centered approach. WJP. 2016;6(4):399-409. doi:10.5498/wjp.v6.i4.399
• Wenze SJ, Armey MF, Miller IW. Feasibility and acceptability of a mobile intervention to improve treatment adherence in bipolar Disorder: A pilot study. Behavior modification. 2014, 38(4):497-515. doi10.1177/0145445513518421
• Valenstein M, Kavanagh J, Lee T, et al. Using a pharmacy-based intervention to improve antipsychotic adherence among patients with serious mental illness. Schizophr Bull. 2009;37(4):727-736. doi10.1093/schbul/sbp121