Or, the patient might improve and continue to take the antidepressant for years, then experience adverse effects after long-term exposure.5,6 Whether antidepressants can sometimes induce mood instability or dysphoria is far from established. To date, this concern is based only on association studies and informed speculation. However, if it were to prove true, some bipolar treatments might not appear so risky by comparison. Contrary to frequent characterization (eg, Frances and Jones7), lamotrigine(Drug information on lamotrigine), lithium, valproate, and carbamazepine(Drug information on carbamazepine)—not atypical antipsychotics—are the relevant mood stabilizers for risk-benefit analyses of overdiagnosis.7 BP-II and many cases of BP-I do not require ongoing antipsychotics for management. Including atypicals in this discussion polarizes the issue unnecessarily and falsely skews the risk com-parison of bipolar treatment.
But the patient awaits treatment. To cope with the twin risks of inaccuracy by oversimplification and immobilization by complexity, consider Hegel’s dialectic concept once again (with thanks to Linehan8 for making this way of thinking commonplace in our discipline). Hegel used the term “aufheben” (literally, to “lift up,” but rich in complexity itself) to describe the dialectic spiral: two apparently contradictory ideas or ways of seeing things interact to produce a synthesis, a new idea, or approach that contains and rises above the contradiction.
Through “aufheben” lenses (left eye simplicity, right eye complexity, if you will), a patient with a differential of GAD+MDD versus BP-II has multiple options. Although the data are slim and unreplicated so far, divalproex as a treatment for GAD is not without precedent.9,10 One might also consider lorazepam(Drug information on lorazepam) or a few days of low-dose olanzapine(Drug information on olanzapine) while gathering more data to understand “how bipolar is he?” (in the manner of the STEP-BD’s “Bipolarity Index”11). You may yet come around to an antidepressant approach after gathering collateral data; eg, if the patient’s partner or close friend endorses few items from a hypomania screening tool such as the HCL-32.12 If psychotherapy remains inaccessible or impractical for him, antidepressants can address both his current anxiety and his mood history. Or you might decide that continued divalproex is the best approach for now.
How is the patient to understand all this? Answer: one step at a time—starting with your counsel that although he could be regarded as having GAD, there are alternative considerations and more investigation is warranted even while his symptoms are being addressed. As you know, many patients follow up their doctor visit with an Internet visit, so helping the patient understand that the diagnosis is not simple and not straightforward may actually save you time later.
In subsequent columns, I’ll use “aufheben” lenses to examine other controversies and challenges. For example: will the new DSM-5 criteria obviate the need for a “Bipolarity Index” approach?