Dr. Andrew Nierenberg is a Professor of Psychiatry at Harvard Medical School and Director of the MGH Dauten Family Center for Bipolar Treatment Innovation. He completed his residency in psychiatry at New York University/Bellevue Hospital.
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https://brain.harvard.edu/?people=andrew-nierenberg
Visit our website for more insights on psychiatry.
Podcast producer: Jon Earle
Dr. Andrew Nierenberg is a Professor of Psychiatry at Harvard Medical School and Director of the MGH Dauten Family Center for Bipolar Treatment Innovation. He completed his residency in psychiatry at New York University/Bellevue Hospital.
Topics:
More information:
https://brain.harvard.edu/?people=andrew-nierenberg
Visit our website for more insights on psychiatry.
Podcast producer: Jon Earle
NOTE: Transcripts of our episodes are made available as soon as possible. They may contain errors.
[00:00:00] DR. THEA GALLAGHER: Welcome to NYU Langone Insights on Psychiatry, a clinician's guide to the latest psychiatric research. I'm Dr. Thea Gallagher. Each episode, I interview a leading psychiatric researcher about how their work translates into clinical practice. Today I'm speaking with Dr. Andrew Nierenberg. Dr. Nierenberg is a Professor of Psychiatry at Harvard Medical School, and Director of the Dauten Family Center for Bipolar Treatment Innovation. In our conversation, we explore the latest on the biology and treatment of bipolar disorder, including new medications and magnetic stimulation. All right. Well, Dr. Nierenberg, thank you so much for being with us today.
[00:00:38] DR. ANDREW NIERENBERG: My pleasure.
[00:00:39] DR. THEA GALLAGHER: So we're just gonna get right into it. And can you start by giving us an overview of your research interests, particularly surrounding bipolar disorder?
[00:00:48] DR. ANDREW NIERENBERG: My research interests, along with my team, range from looking at some molecular aspects all the way to health care system change, and everything in between.
[00:01:00] DR. THEA GALLAGHER: And why did you decide to devote your career to bipolar disorder? Can be so challenging to know, you know, which area of interest or research focus you're going to take. So what kind of led you to this path focusing on bipolar disorder?
[00:01:12] DR. ANDREW NIERENBERG: So I was a depression researcher for many years. And then my chairman asked me to go help out in the bipolar-
[00:01:19] DR. THEA GALLAGHER: [laughing].
[00:01:19] DR. ANDREW NIERENBERG: ... Clinic at the time and research program, because they were short-handed, and they were running a huge project. So, that was in 2000. And I shifted over too much more bipolar work ever since then.
[00:01:33] DR. THEA GALLAGHER: And it sounds like you got put into that position, but have you enjoyed doing the work and the research in that area, like, as a result?
[00:01:41] DR. ANDREW NIERENBERG: Oh, yeah, no, it's been absolutely great. And it's so much more complicated than depression.
[00:01:47] DR. THEA GALLAGHER: Hmm. Mm-hmm.
[00:01:48] DR. ANDREW NIERENBERG: And there's so many more challenging aspects to it, and things that need to be improved.
[00:01:54] DR. THEA GALLAGHER: Can you tell us ab- about some of those complications? Or what about bipolar disorder, you find so interesting and important?
[00:02:01] DR. ANDREW NIERENBERG: So one of the things about bipolar disorder that's most challenging is that it's associated with the most number of comorbid conditions out of all of the disorders. So people are really complicated. The other thing is, it's an early onset, it's very long term, it comes and goes. And it's extremely challenging to get people all the way better from an acute episode and keep them better. And even if you get them better, there are a lot of, let's call them residual symptoms that persist like insomnia, even though they're feeling okay. So there's great uncertainty in terms of how to treat them, what combinations to use, how to best treat bipolar depression, how to treat anxiety, how to be able to make sure that someone doesn't get manic, having some balance between the efficacy of the medications, along with the side effects, the need for psychotherapy, specific psychotherapies, lifestyle interventions, and wellness interventions. They're all important.
[00:03:08] DR. THEA GALLAGHER: So I guess when we're talking about the way the field has changed with a lot of people that have come on the podcast, they've been doing this work for a long time, sounds like you've been doing this work specifically, since 2000. But what are some of the key takeaways, um, that the treatment of bipolar disorder has changed over the course of your career? Like what's been, yeah, some of the changes, improvements, maybe things we're not doing, things we are doing now?
[00:03:33] DR. ANDREW NIERENBERG: So I think one of the key changes is the replacement of lithium with antipsychotics. So there's been maybe a 50 percent drop in the use of lithium in the United States, and a concomitant increase of all of the newer antipsychotics. It's unclear if that yields better outcomes or not, but nothing really has beat lithium over the long term. So that's one of the problems, right? And, and the other problem is that the most common treatment that's used for bipolar depression is a combination of an antidepressant plus an antipsychotic, and outside of olanzapine, fluoxetine, no other combination has been shown to work or not work, it just hasn't really been studied. So it's, it's, uh, it's a really interesting problem.
[00:04:25] DR. THEA GALLAGHER: And when you're talking about the lithium versus antipsychotics, what is the problem there exactly?
[00:04:32] DR. ANDREW NIERENBERG: Well, th- the problem is that lithium probably changes the course of the disorder for the better.
[00:04:39] DR. THEA GALLAGHER: Hmm.
[00:04:40] DR. ANDREW NIERENBERG: It is not clear if the antipsychotics do the same thing. The other thing is that lithium is uniquely associated with a decrease in all cause mortality, and-
[00:04:52] DR. THEA GALLAGHER: Hmm.
[00:04:52] DR. ANDREW NIERENBERG: ... The antipsychotics are not. Now, it's always a trade-off of side effects. But if you just look at the long term efficacy, maybe the 30 percent of people who really do well with lithium, lithium beats all the other treatments. Now, very few people are on lithium alone, it's probably less than 1 percent. So there are still other things that need to be taken care of. But there are rational combinations like lithium plus lamotrigine that can keep people stable over the long haul.
[00:05:24] DR. THEA GALLAGHER: And is your research looking at any of these combinations, or is there research that is looking at trying to find the optimal combination of medications that are sustainable and have durability?
[00:05:36] DR. ANDREW NIERENBERG: So we are about to launch two large initiatives that may address the questions that you just had. One initiative is the biggest study of bipolar depression that's ever been done. It's called SMART BD. And SMART is an acronym for Sequential Multiple Assignment of Randomized Treatment, it's funded by the Patient-Centered Outcome Research Institute, we'll be able to randomize 2,800 people to four competing treatments. And one of those treatments is the specific combination of escitalopram and alprazolam. And then we're comparing it to quetiapine, lurasidone and cariprazine. And believe it or not, these meds have never been compared-
[00:06:27] DR. THEA GALLAGHER: Hmm.
[00:06:28] DR. ANDREW NIERENBERG: ... Ever. No one has ever compared them, both in terms of short term, long term. And it's a pragmatic trial. So it means that you could add it to whatever people are taking besides those drugs. And then it's a SMART design, Sequential Multiple Assignment of Randomized Treatment because if they don't do well after the first six weeks, they get randomized to what they didn't get. If they do well in either the first stage or the second stage, we follow them up to 52 weeks. If they don't do well, after the second stage, the second six weeks, the total of 12 weeks, we're gonna figure out what to do with them using guidelines, best principles, but also observational.
So my hope is that this really will inform clinicians. And the other thing is that we're using a multiple machine learning algorithm that could generate for any individual, the probability of responding to any one of the four competing treatments. So that's what we hope to get at the end of the day. And we're just about to start that. There's some logistics that we have to take care of, but my hope is, uh, we'll be able to start it by the summer. An- and that's fully funded. The other thing that we're doing, which is a little harder to explain, but we're borrowing a paradigm from Cincinnati Children's Hospital, called the learning health network.
And the learning health network is a completely different way to have patients, families, clinicians, researchers, data analysts, administrators, healthcare systems, insurance companies collaborate all to get better outcomes. And the model that comes out of Cincinnati Children's Hospital, has been successfully deployed 15 times with results that are nothing short of stunning. And, for example, one of the oldest of the networks that they built is called ImproveCareNow, that focuses on 30,000 kids and young adults with Crohn's, Colitis, and inflammatory bowel disease. And when they started this about 15 years ago, the state of the field was a mess. People were doing all sorts of things. No one knew what the outcomes were. They weren't doing systematic assessments or systematic follow up.
And, uh, what they built was an entire system based on collaborating in a way that's never been done before, where patients, clinicians and researchers all have an equal say in what's going on. And because it uses a network organization, anybody can lead any sort of initiative. So when they first measured what was going on, the readmission rate was about 55 percent. And then using very sophisticated methods of quality improvement, and looking at how different health care systems had different outcomes, and then fostering a culture of collaboration, generousness, humility, curiosity, and trust, the centers that weren't doing so well were able to learn from the centers that were doing so well. And then using quality improvement cycles, they saw what would happen if they deployed what was going on in the better sites. So using this method, with no new treatments, they raised the remission rate from 55 percent to 82 percent-
[00:10:22] DR. THEA GALLAGHER: Wow.
[00:10:22] DR. ANDREW NIERENBERG: ... Within three years. And again, this has been repeated again and again in very difficult complex, chronic disorders. So this will be the first time this model will be applied to psychiatry. And so we're just now building the, uh, Bipolar Disorder Learning Health Network, we'll probably have some better name for it, e- eventually, uh, within the next year. Um, and we're doing a very systematic planning and design phase that will take about nine months starting now. And we have about 19 health care systems, including NYU-
[00:11:01] DR. THEA GALLAGHER: Oh, neat.
[00:11:01] DR. ANDREW NIERENBERG: ... that are interested.
[00:11:03] DR. THEA GALLAGHER: Mm-hmm.
[00:11:03] DR. ANDREW NIERENBERG: And we're gonna do kids, we'll do adolescents, we'll do adults, we'll do geriatrics, we'll be focusing on anything that helps, including, you know, medication, psychotherapy, peer support, whatever works. Um, we have DBSA as a partner in that, and also, um, the NIMH. So it's an experiment, we'll see. We don't know what will happen with it. But I'm really excited that I think we can do all sorts of things and discover what works, what doesn't work and be able to test it very, very quickly, so that even if there are new treatments, we can see what the actual real world outcomes are, because we don't know, nobody ever does.
[00:11:50] DR. THEA GALLAGHER: Yeah, and we always talk about, you know, translating research to practice. And this is almost like translating practice to research like learning from what's actually happening.
[00:11:58] DR. ANDREW NIERENBERG: So there, there, there is a term that's called medicine based evidence-
[00:12:02] DR. THEA GALLAGHER: Hmm.
[00:12:03] DR. ANDREW NIERENBERG: ... Uh, that comes from a guy named Ralph Horwitz. And it's, it's really not just using the evidence and not just using the data, and not just looking at it from a technical point of view. But the heart of it is building the culture. And by the way, the healthcare systems agree to have their data be transparent to each other, but to never use those data competitively.
[00:12:32] DR. THEA GALLAGHER: It sounds like some of the goal here, because since it's like a systems level approach, is, is some of the goal here to have, um, more people following the standard of care, but then also learning that there are new elements like new pieces to the i- inner, new interventions or new aspects of the interventions that also work?
[00:12:54] DR. ANDREW NIERENBERG: Yeah, it's that and th- there are some fundamental gaps that we have. There's no systematic assessment. There's no systematic diagnosis. There's no systematic or reliable follow up in a way that can inform both the patients and their families and the clinicians. So in a sense, the group has to agree to what's the minimal standard of practice that would help, then that data will be transformed into usable dashboards, so that essentially, the entire system knows how it's doing every single month. What's really important about the culture in the group, is that the culture in the group determines what are the, what are the goals that matter the most. So is it access to care? Is it, uh, hospitalizations? Is it death by suicide? Is it cardiovascular disease? And what's the system by which people get their medical care? That's haphazard and chaotic.
So it's trying to address all of those problems, but one by one in a way that you can come up with solutions that really get better outcomes. And just imagine, you know, you see patients, you see patients one on one, what happens to those data? You don't know. Well, what would happen if every single encounter you had was building a knowledge base, and a database that you also had access to? And the ultimate goal for any clinician, for example, would be to be able to see a patient have a systematic assessment that maybe the patient does mostly so it's not a burden. But then once you have a profile of a patient, you could look at the database and see 5,000 patients just like this one and their outcomes-
[00:14:58] DR. THEA GALLAGHER: Hmm.
[00:14:58] DR. ANDREW NIERENBERG: ... And what treatments seemed to work best. And plus you could see in the database what is actually working and what's not. And for whom. And then collectively, there's also a community of clinicians that can share stories, debate things, ask questions, and then what you have is crowdsourcing. That's the whole goal.
[00:15:23] DR. THEA GALLAGHER: Yeah. And then you have like a, you know, like you said, a standard of care, and then learning if there are things that you didn't even consider that might be helping a large group of people, or might be helping a certain group of people. And that's another theme that continues to come up in the podcast, because I think it's continuing to come up in psychiatry, which is this personalized medicine approach, really understanding that people are different, and they might need nuances, um, and there might be something about their profile, that means that they need a little bit more of this, a little less of this, you know, an adjunctive of this. Um, and I think, again, having these large databases will be helpful it seems like in making some of those determinations.
[00:16:02] DR. ANDREW NIERENBERG: Right. And, and, you know, look, think of your own practice, do you know the outcomes of your patients? Probably not.
[00:16:08] DR. THEA GALLAGHER: Mm-hmm. Mm-hmm.
[00:16:08] DR. ANDREW NIERENBERG: And, and so this would help you know what are the outcomes of your patients, what are the outcomes of other people's patients? How can you put that together in a way that you have a constant learning engine, so you're constantly learning from each other? And I've seen this in action, and attended some of the ImproveCareNow gatherings, they're really just extraordinary. It enriches clinical practice, the patients and their families can also come up with solutions. And one of the things that I was most impressed with... Right, ImproveCareNow is 30,000 kids. Right. 30,000 kids with inflammatory bowel disease, well, some of them have to get infusions frequently, and one of the adolescents wanted to feel more comfortable and wear her hoodie. But she couldn't, because you can't roll up the sleeve.
[00:17:01] DR. THEA GALLAGHER: Hmm.
[00:17:02] DR. ANDREW NIERENBERG: So she got a small grant, designed a hoodie that had a zipper in the sleeve-
[00:17:06] DR. THEA GALLAGHER: The sleeve? Okay.
[00:17:07] DR. ANDREW NIERENBERG: ... And started a company.
[00:17:08] DR. THEA GALLAGHER: Mm-hmm.
[00:17:09] DR. ANDREW NIERENBERG: And this became a solution to a problem that the clinicians didn't even know about. And, and, you know, the kids love it. So, that's the sort of thing that can happen in the network organization is that people have the opportunity to initiate projects and then test to see if they work.
[00:17:29] DR. THEA GALLAGHER: Yeah, it's kind of like I think, I think with psychiatry there's still this understanding is like, behind the curtain, and actually, like, bringing things out and creating these almost like consortiums, but like, you know, everyone collaborating and working together with the goal of best practice for our patients. And I think ultimately, that's what every clinician and researcher wants.
[00:17:47] DR. ANDREW NIERENBERG: Right. Right. But, but, you know, the system is not built for that now.
[00:17:51] DR. THEA GALLAGHER: Right. Mm-hmm.
[00:17:51] DR. ANDREW NIERENBERG: And so that's why we want to shift the system to be able to, to do this.
[00:17:56] DR. THEA GALLAGHER: Mm-hmm. And is there something particular about bipolar disorder that makes it like a little bit more of a moving target or a little bit more challenging with regard to treatment? So, you know, I treat a lot of people with OCD, and we have a lot of great, you know, RCTs that show exposure and response prevention treatment works. And so you give the SCID screener and then you do the Y-BOCS and then you do the ERP and you give the Y-BOCS again, and you see symptoms, you know, obsessions and compulsions decrease and great and we move on. Is there something about even treating bipolar or something that even that makes, that makes it more challenging? Or e- especially because of the medication aspect, which would also make this database even more helpful? Like, are there more aspects to it?
[00:18:42] DR. ANDREW NIERENBERG: I think one of the big problems with our evidence base, and especially the RCTs, is that the RCTs don't include people who are really sick, and that the RCTs exclude everyone who has suicidal thoughts and behaviors. And then, it excludes all the people who have comorbid substance use disorders, they don't get into the RCTs.
[00:19:08] DR. THEA GALLAGHER: Hmm.
[00:19:08] DR. ANDREW NIERENBERG: What do you do for those people? You know, what's, what's the evidence for it? So i- it's all of these types of complications, in addition to the fact that like OCD and other psychiatric disorders, it's dynamic, it changes over time. Um, it has a very complex shifting structure. So you can have somebody with psychosis, somebody with anxiety, somebody with chronic depressive symptoms. And then the other thing is that most people have mixed symptoms. People with depression have manic symptoms. People with mania have depressed symptoms. They also have this other aspect of anxiety, in addition to circadian rhythm disruptions, and so forth. So it's extraordinarily challenging to get these people to well, and to keep them well, in collaboration. Plus, I just saw a study that basically 40 percent of people with bipolar disorder just don't take their medications in a good enough way that it helps them the most. So that's the other thing in terms of the partnership shared decision making, making sure that, that i- it's a collaboration between the clinician and the patient.
[00:20:31] DR. THEA GALLAGHER: In, in order to, like, in that that relationship might bolster adherence?
[00:20:36] DR. ANDREW NIERENBERG: Well, we, we like to use the word concordance.
[00:20:39] DR. THEA GALLAGHER: Okay, I knew we don't use, um, what's the other one that we don't use anymore?
[00:20:42] DR. ANDREW NIERENBERG: Compliance.
[00:20:43] DR. THEA GALLAGHER: We don't use compliance, I thought we use adherence, and now we use concordance. Great. I would love to learn.
[00:20:47] DR. ANDREW NIERENBERG: Yes. It, so the concordance is you agree on a goal and how to get there.
[00:20:52] DR. THEA GALLAGHER: Mm-hmm.
[00:20:52] DR. ANDREW NIERENBERG: And if there's a problem where the person you're working with can't quite do that, you discuss it. What's getting in the way? You know, what's, what's your goal here?
[00:21:02] DR. THEA GALLAGHER: Yeah. Tha- that feels very, like, you know, um, collaborative and almost like motivational interviewing, right? Like, how can we get to the same... The goal that everybody wants and making it less hierarchical, more collaborative? And that can be a real factor, it seems, in helping people, you know, be able to maybe find that motivation to take their medication, et cetera or whatever barriers might be there.
[00:21:24] DR. ANDREW NIERENBERG: Yeah. I think it's a big gap in our education, because we negotiate with patients all the time.
[00:21:29] DR. THEA GALLAGHER: Mm-hmm.
[00:21:29] DR. ANDREW NIERENBERG: And it's not just motivational interviewing, it's using the best principles of negotiation that we could possibly use. Um, there's a really good book called "Never Split the Difference". And, it can give you some tools on how to negotiate, especially under difficult conditions.
[00:21:50] DR. THEA GALLAGHER: Especially like working with your patients to negotiate for ultimately the same goal.
[00:21:55] DR. ANDREW NIERENBERG: Yeah. Right. And, and, you know, I think all too often, people get sucked into an adversarial negotiation. And it doesn't have to look that way.
[00:22:05] DR. THEA GALLAGHER: Yeah. Um, and it sounds like, you know, the systems level intervention is really unique, and different from some of the things we've been talking, uh, about on the podcast, which are, you know, novel treatments, new medications, but are there any, you know, new treatments, medications that do seem particularly promising to you, as you look forward?
[00:22:25] DR. ANDREW NIERENBERG: Well, there are several biotechs that are trying to use a different approach, and using really interesting models, ranging from, uh, zebrafish to brain organoids, uh, to try to see what, what are the profiles of the meds that seem to work? Um, you know, how does it affect transcriptomics, proteomics, and so forth? And are there other medications that are already out there that might be able to do the same thing? So one of the interesting drugs that is being looked at to repurpose, believe it or not, is candesartan. Uh, there are also, uh, drugs like the old fibrates, um, because of the pathways they affect. There currently aren't many things that approximate lithium itself. And there aren't enough things that are alternatives to the antipsychotics.
But among the antipsychotics, one of the most interesting ones is pimavanserin. And pimavanserin is approved for the use of treating people with Parkinson's who have psychosis. And what's interesting about pimavanserin is it doesn't touch dopamine. And I think ultimately, the dopamine blockers can make people feel dulled, and maybe pimavanserin could be an alternative to that. Uh, so I think some of those drugs are interesting. I think some of the neurotherapeutics are interesting, especially some aspects of deep brain stimulation and closed loop systems. That might be interesting. There's also, believe it or not, a strain of research that's looking at using near-infrared transcranial light, that has interesting effects on mitochondria, and on neuro protection, uh, that is actually being used for traumatic brain injury. But it's never been used for bipolar disorder. There are preliminary data for depression. So that's another interesting neurotherapeutic intervention.
[00:24:39] DR. THEA GALLAGHER: You've written about the importance of large scale pragmatic trials and machine learning. Uh, you've talked a little bit about how you hope to see machine learning and AI contribute to new treatments, and better treatment regimens. Is there anything that we didn't cover with regard to that area?
[00:24:56] DR. ANDREW NIERENBERG: I don't think so. I thi- think that there can be a bit of an overhype and an over promise of what machine learning can actually do, um, but ultimately, I think there are going to be novel ways to look at big data and to look at the medicine based evidence to learn new things that otherwise we would not have learned. We'll see what, how that turns out.
[00:25:23] DR. THEA GALLAGHER: Yeah. And, just to build off of that, uh, a couple of years ago, i- in editorial you said, “As a practicing psychiatrist who specializes in treating depression and bipolar disorder, I frequently must find solutions for problems for which no data exist.” And I'm sure our listeners really can relate to that. So how do you approach treatment when data is lacking?
[00:25:44] DR. ANDREW NIERENBERG: So we function under conditions of uncertainty, and that for most of our clinical questions, there are not clear answers. And even when there are answers, the answers have to do with probability and not absolute certainty about what will work or what will not, we only know once we give somebody a treatment. So I think what we do is try to make the best decisions we can with the best probabilities given the information that we currently have. But this is why I'm actually excited about the bipolar learning health network, because in many ways, it addresses the epistemology of clinical work. How do you know what you know? And how do you actually know if it's working? Um, because the, again, the RCTs don't necessarily inform clinical practice of most of them, get drugs registered for the FDA.
That's the purpose, to show that there is some difference or reasonable difference, or enough of a difference between active treatment and placebo. So, in all of medicine, most trials don't inform clinical care. And so you have to do the best that you can, with integrating the so-called idiographic data, right? The data from the individual, with the best available data for people on average. And that's the problem, because we just have it on average. And, then I think if we collect the outcomes and look at that, we have a better chance of knowing what to do, because, again, we function in the cloud of uncertainty. And in many ways, the whole move towards personalized medicine, precision medicine, is to be able to decrease that cloud of uncertainty to make better decisions and to have better outcomes.
[00:27:41] DR. THEA GALLAGHER: Mm-hmm. And to be able to treat the people who, you know, the percentage of people who don't respond to the standard of care, and like you're saying, the percentage of people who have already been excluded from the trials that still need to be treated.
[00:27:56] DR. ANDREW NIERENBERG: Right. And, although there's a lot of research being done on fMRI, and looking at the different sort of patterns you could have an fMRI. Leanne Williams out of Stanford is looking at that with depression. It's still, it probably is not practical to do that at this point, it's just too expensive. Um, but I think ultimately, there is still a desire for all of us to have better biomarkers that will guide treatment a little bit better than what we have now. Because currently, we don't have any biomarker that will help determine treatment.
[00:28:33] DR. THEA GALLAGHER: Mm-hmm. Yeah, psychiatry is a little bit in the Dark Ages.
[00:28:36] DR. ANDREW NIERENBERG: Well, I, I wouldn't quite be, yeah, I wouldn't be that negative. I think we're dealing with-
[00:28:43] DR. THEA GALLAGHER: [laughs].
[00:28:43] DR. ANDREW NIERENBERG: ... You know, an entirely complex, dynamic system of the brain. And it, there's nothing that's linear, there's nothing that's, that's straightforward. So it's not a surprise that there's no single biomarker. But I think ultimately, we might have a suite of-
[00:28:59] DR. THEA GALLAGHER: Yeah.
[00:29:00] DR. ANDREW NIERENBERG: ... Biomarkers that may be able to help us a bit. Uh, there's an interesting guy in Indiana, um, Alexander Niculescu. And, um, he has a whole company that's looking at this and some data that looks at it. And although I don't think it's the answer, I think it may be the strategy to try to get to the point that we can have more, not only biological data, but, uh, you know, as you know and everyone knows, uh, someone's history, and if they've had trauma, uh, what's their social situation? What are the social determinants of health? And, integrating all of those things may be able to help us a little bit more.
[00:29:45] DR. THEA GALLAGHER: Yeah, and that's where, you know, machine learning, AI will be able to really help us push that forward in, you know, the next number of years.
[00:29:55] DR. ANDREW NIERENBERG: Yeah, and, and you know, it's one thing that, that I know it's hard to predict what the heck is going to happen, but-
[00:30:01] DR. THEA GALLAGHER: Mm-hmm.
[00:30:02] DR. ANDREW NIERENBERG: ... It's certainly going to be interesting.
[00:30:04] DR. THEA GALLAGHER: And the fact of just, I think, collecting more data points, collecting more information. And I like that you're even looking at it from the system's level from the individual level. Um, I think together, all of that data, making meaning of that data will definitely be able to inform treatment and treatment regimens for patients.
[00:30:24] DR. ANDREW NIERENBERG: Right. And, it's actually a very interesting model in France. And the model in France was put together by Marion Leboyer. And she organized centers of excellence of bipolar disorder, they gathered the data in the same way. And they used a structure where there were consultations done for the clinicians. And just with those consultations, they reduced hospitalization rates by 50 percent.
[00:30:52] DR. THEA GALLAGHER: Hmm.
[00:30:52] DR. ANDREW NIERENBERG: So that's why if you bring people together and look at things a little bit more systematically, and collaborate together, uh, so that you have this crowdsourcing, I think that, that has tremendous potential in helping people suffer less, live better, have more wellness.
[00:31:10] DR. THEA GALLAGHER: Yeah, and what's also hitting me now that you're talking is there's always been such a separation between the clinician and the researcher. And I think it's interesting now, even looking to the clinician and looking to the other maybe providers or people on the treatment team, as, you know, informants of also of what's happening, and that they are doing research in real time. And you used a phrase earlier, it was called medicine-
[00:31:37] DR. ANDREW NIERENBERG: Based evidence.
[00:31:38] DR. THEA GALLAGHER: ... Medicine-based evidence. And I think, um, I think that's also a neat concept that we might ultimately see as more collaboration between researchers and clinicians. Do you hope for that as well?
[00:31:48] DR. ANDREW NIERENBERG: Oh, yeah. And, and, you know, if you just think of it, look at all the measures that are used in research, they're not used in clinical practice.
[00:31:55] DR. THEA GALLAGHER: Right. Right.
[00:31:56] DR. ANDREW NIERENBERG: And so, wait a minute, there's a little gap here, what are you talking about? [laughs].
[00:31:59] DR. THEA GALLAGHER: Mm-hmm. Yeah, and it can feel almost like hierarchical too. Uh, and, and I've been in clinics where there's heavy research people and heavy clinical people. And there can definitely feel a disconnect in that neither one is understanding each other. And in this method, or this intervention, or whatever you're calling it, the platform, the systems level intervention will kind of consider both perspectives helpful, and work together to, to make that connection between research and clinical practice.
[00:32:28] DR. ANDREW NIERENBERG: Right. And, and if people want to learn more about it, it comes out of the Anderson Center at Cincinnati Children's Hospital. And if you Google that, the Anderson Center, Cincinnati Children's Hospital and learning health networks, they have a lot of material there, in there that's really interesting. Um, and there's also a, uh, video podcast from a company called Wondrus. W-O-N-D-R-U-S. And if you Google "Wondrus and learning health networks," you get about a 30-minute video that describes the whole concept, where one of the people in the video, who's the head of the Institute for Healthcare Improvement, actually says it may eventually be malpractice to not be in a learning health network.
[00:33:17] DR. THEA GALLAGHER: Yeah, and it seems more complex and robust than just guidelines. It seems like-
[00:33:21] DR. ANDREW NIERENBERG: Well...
[00:33:22] DR. THEA GALLAGHER: Yeah.
[00:33:22] DR. ANDREW NIERENBERG: Gu- guidelines, guidelines don't work.
[00:33:26] DR. THEA GALLAGHER: Right.
[00:33:26] DR. ANDREW NIERENBERG: And the reason that guidelines don't work, nobody reads them. Nobody uses them. You know, they're kind of an academic, you know, what's the best evidence that's available from quite frankly, highly flawed evidence, that's not meant to inform clinical care.
[00:33:43] DR. THEA GALLAGHER: Mm-hmm.
[00:33:43] DR. ANDREW NIERENBERG: So guidelines sound great. And, and, you know, it's better than not having guidelines. But, you know, I was recently talking to the people at the VA, and they have guidelines that very few people use, and they don't know how to get them to use it. And I think that that's why it has to be this collaborative effort of, well, you know, look at what's happening now, and if you do some of the guidelines, well, you get better outcomes. Because the ultimate question is, if you use guidelines, does it actually help? So, so, you know, going at a very granular level of how do you make decisions in the moment with a patient, regardless of what their diagnosis is, you know, I just focus on bipolar disorder, but all of the factors that have to come into play, to get the best decision to get the best outcome, it's really complicated.
[00:34:38] DR. THEA GALLAGHER: Yeah, and especially complicated with, uh, mental health, I would imagine.
[00:34:42] DR. ANDREW NIERENBERG: Well-
[00:34:43] DR. THEA GALLAGHER: And if learning health networks... Is that going to be the first one looking at mental health?
[00:34:48] DR. ANDREW NIERENBERG: Uh, there, there is one that's sort of done with autism, but not in any of the, you know, sort of major psychiatric, uh, disorders. But I, I'd also have to point out, this is true in all of medicine.
[00:35:02] DR. THEA GALLAGHER: Mm-hmm.
[00:35:03] DR. ANDREW NIERENBERG: It's not just psychiatry. And, uh, a few years ago, there was an analysis of the American Heart Association guidelines, and only 15 percent of the guidelines were actually backed by actual data. So it's a problem in all of medicine of how do you actually make the best decisions in the moment that have the best outcomes?
[00:35:24] DR. THEA GALLAGHER: And if you could, you know, wave a magic wand and cause one major shift in how clinicians treat bipolar disorder, what would it be?
[00:35:31] DR. ANDREW NIERENBERG: I, I, I think the, the, the most basic thing would be for people to be systematic about the diagnosis. Because what I've seen is over diagnosis, especially people with depression with irritability, or severe anxiety, and anxious rumination, which people call racing thoughts, which it's not, or more often, you see people have depression and they actually have bipolar disorder, but nobody ever asked them about past manic or hypomanic symptoms. So I think just being systematic, and, and being able to use the available criteria as best as possible to make the best diagnosis that you can.
[00:36:15] DR. THEA GALLAGHER: And just my last question here, so what, what advice would you give to clinicians who are eager to both, you know, keep up on the research on bipolar and integrate the latest findings into their work?
[00:36:26] DR. ANDREW NIERENBERG: Um, I, I wish I had a simple answer to that. [laughing]. I know how busy clinicians are, and I know how long the days can be of trying to help people who are suffering so much. It's very hard to keep up with literature. And it's, it's, it's a challenge to know what is most salient. And again, I would ask you, you know, what have you read in the past year that changed your practice? Probably very little. So I, I, I think that certainly going to conferences, um, and, and trying to learn as much as you can and have lifelong learning is the best way forward. But I, I think there's no, there's no clear way to do that, except by hard work.
[00:37:16] DR. THEA GALLAGHER: Yeah. And I guess for some people listening, if they are a part of, uh, one of these larger medical systems that it seems like you might be collaborating with for this learning network, that could be a great way for them to continue to learn and grow in their practice.
[00:37:30] DR. ANDREW NIERENBERG: Uh, again, I hope so. We'll see how this thing launches. We'll see what it looks like in a year or two. But based on the development of the other learning health networks, I think we could make an impact within three years.
[00:37:44] DR. THEA GALLAGHER: Well, looking forward to seeing all that the work that you're doing and how it comes to fruition. Thank you so much for speaking with me today.
[00:37:50] DR. ANDREW NIERENBERG: Thanks so much for inviting me. It's been a pleasure.
[00:37:54] DR. THEA GALLAGHER: Thanks so much again for that conversation, Dr. Nierenberg. If you enjoyed this episode, be sure to rate and subscribe to NYU Langone Insights on Psychiatry on your podcast app. For the Department of Psychiatry at NYU Langone, I'm Dr. Thea Gallagher, see you next time.