Comments on Treatment Conundrums
Sir William Osler
Clinical medicine is an art and as medical pioneer Sir William Osler declared, often involves “skillful use of combinations.” As the risks of inadequately treated illness increase, use of drugs with inadequately delineated benefit-to-risk ratios may be increasingly justified, such as in the case of memantine as recommended by Koukopoulos.
One should start early, effective, preventive pharmacological treatment of the recurrent unipolar and bipolar disorders. When this is not accomplished, an increasing number of unknowns enter the treatment equation, and as these illnesses enter more serious stages of recurrence, progression, and treatment resistance, the path to remission and wellness becomes increasingly complicated and relies on skillful management, guesswork, and good data from patients.
Given the multiple unknowns, patients can play an important role. They can be intimately involved in the decision-making, and provide precise feedback in the formal or informal longitudinal monitoring of mood, sleep, other symptoms, and side effects so that whatever is tried can be accurately assessed. A treatment with known efficacy is only worthwhile if it is effective in a given patient. When evidence of efficacy in the literature is more questionable, the evidence of effectiveness of a given treatment regimen in a given individual becomes all the more important to discern. We recommend that patients chart their mood and medications using the National Institute of Mental Health’s Life Charting Method (NIMH-LCM) or another type of personal calendar (we offer several on our Lifecharting page–see the gray horizontal menu above this article). This type of careful longitudinal monitoring method can help in the quest for an optimal treatment result.
Our old recommendation would appear particularly appropriate for this discussion. When things are going well (in the treatment of recurrent mood disorders), be conservative and stay the course. Conversely, when mood is not stabilized, be more radical and continue to explore new options until stability is achieved.
Mobile Apps and Other Technologies May Make It Easier to Track Mood Symptoms Longitudinally
Multiple investigative groups at the 9th International Conference on Bipolar Disorder (ICBD) held in Pittsburgh in 2011 reported on the use of mobile phones or other automated processes to provide a more detailed ongoing record of a patient’s mood fluctuations and response to treatment. A particularly notable study by Nolen and colleagues described an electronic version of the life chart method (e-LCM) that would be accessible via internet, and which could be integrated with the patient’s file and used for research. These investigators developed software for a patient version and a clinician version. The web-based version is not yet available for patient use.
Editor’s Note: Until this and other useful electronic monitoring procedures become available, we recommend using the written version of a life chart to provide daily assessments of mood, side effects, and comorbid symptoms in order to provide a detailed numerical and graphic record with which to judge treatment response. This method is extremely valuable in developing new treatment approaches for those with treatment-resistant illness, and if patients keep these records, physicians will have optimal and detailed input in order to assess response and make treatment recommendations.
Sample Mood Chart
My Mood Monitor provides another available approach. This system was developed primarily as a screening instrument, but also includes a longitudinal monitoring component. It is not designed for daily monitoring, but can be used repeatedly with a minimal interval of one week between ratings.
We’ve written before about depressioncheck, My Mood Monitor’s iPhone app that can quickly screen for mood and anxiety disorders.
Track Your Moods with Life Charting
If you have unipolar depression or bipolar disorder and are having trouble stabilizing your mood, we recommend nightly charting of mood, medications and side effects on the easy-to-use Monthly Mood Chart Personal Calendar (pictured below) or the National Institute of Mental Health Life Chart (NIMH-LCM), both of which are available for download.
Sample Mood Chart
Click on the Life Charts tab above to download the personal calendar, which includes space for rating mood, functioning, hours of sleep, life events, side effects, and other symptoms such as anxiety. Then bring the chart to each visit with your physician to help in the assessment of treatments.
Life charting can help determine which medications are working partially and need to be augmented further, and which need to be eliminated because of side effects. Since there are now many potential treatments for depression and bipolar disorder (some FDA-approved and some not), a careful assessment of how well each new treatment works for a particular patient is essential to finding the optimal treatment regimen.
