As a fourth-year psychiatry resident, the thought of completing training and entering the “real world” can be quite daunting. For me, a symposium at APA 2015, “Evidence-Based Psychopharmacology: Algorithms to Guide Clinical Decisions for Treating Bipolar Disorder,” translated into “if you’re worried about making mistakes, follow these key points and you should at least be okay for treating patients with bipolar disorder.”
Walking into the symposium, I figured we would simply be following along some type of flow diagram or decision tree. What I didn’t see coming was a tectonic shift in my conception of the disorder—particularly the depressed phase.
From the first day of training, we are repeatedly cautioned about the use of antidepressants in patients with bipolar disorder and the risk of causing a switch from a depressed phase into a manic phase. The state of irritability, impulsivity, poor judgment, and potential compromise in reality testing is feared for its potential to bring harm to the patient and to others. While the manic phase is arguably the “sexier” of the two poles, we may not always focus closely enough on the target of euthymia instead of simply “getting out of mania.” This may have been the first time I can recall being formerly cautioned about causing a switch from a manic to a depressed state.
Patients can be weighed down with the negative emotional and cognitive cloak of depressed mood while still having the leftover goal-directed and physical energy of the manic phase from which they came. This can be disastrous for obvious reasons. We may have helped our inpatients out of a manic phase before they are discharged. However, the stability we see at this time may be a temporary state and may herald a depressive episode. Thus, it is crucial to have a high level of vigilance for depressed features and to ensure follow-up within 7 days—at which time we can still intervene if needed.
On average, patients with bipolar disorder spend approximately two-thirds of their time in a depressed or euthymic state. Thus, effective treatment of depressive symptoms is paramount to preserving safety and quality of life. To this end, Drs Dana Wang, David Osser, Arash Ansari, and Othman Mohammad presented a beautifully detailed algorithm for treatment options—for the depressed phase of the illness as well as the manic phase.
Dr Prabhu is Chief Resident in the Department of Psychiatry and Neuroscience at Detroit Medical Center/Wayne State University.