Current medications

None

Question

What does a family history of, or lack thereof, bipolar disorder mean clinically?

Nothing, as there is no clear bearing on risk of bipolar disorder or treatment outcomes

Risk of bipolar disorder appears clear as family, twin, and adoption studies have provided evidence for a strong genetic component to bipolar disorder

• – Particularly, twin studies demonstrated higher concordances for the disorder among monzygotic identical twins, as compared with dizygotic fraternal twins, with an estimated heritability >80%

• – People with a first-degree relative with bipolar disorder have a 13.63-fold increased risk of developing bipolar disorder themselves

Attending physician’s mental notes: initial evaluation

This patient is somewhat complex given his MDD, SAD, and AUD comorbidities

He has had two spells consistent with hypomania symptomatology, but the origin of these symptoms might be due to the SSRI treatments, his alcohol abuse, or frank onset of bipolar illness

He has no family history of bipolar disorder, which seems to decrease his bipolar risk 13-fold

His multiple SSRI-induced activations are often considered to be bipolar disorder prodromes or sentinel events and are troubling

Many bipolar patients appear to be unipolars with anxiety problems in their young adult years but progress toward bipolar disorder as they age

He is undertreated in that he has not had a full trial of any psychotropic

Question

Which of the following would be your next step?

He is euthymic, thus do nothing and await any symptom relapse, then choose an appropriate medicine to match his affective state

Collect collateral information from relatives to better delineate his mood elevations to determine if he is bipolar I, II, or neither

Start a mood chart to observe in real time any mood swings that he might develop to better delineate his diagnosis

Issue a rating scale such as the MDQ to better delineate his bipolar diagnosis

Start an approved mood stabilizer for presumed bipolar II disorder

Start another antidepressant for his SAD, while watching for mood elevation in real time

Start a BZ sedative for his SAD to avoid mood-elevating side effects that have been noted previously when he used SSRIs

Attending physician’s mental notes: initial evaluation (continued)

This patient seems to be either very sensitive to excessive mood-elevating side effects from his SSRI treatments, or he is a relatively new bipolar II disorder patient

Collateral information suggests that his two hypomania spells were clearly preceded by SSRI use and excessive alcohol use

His behavioral and legal problems occurred after the mood elevation was noted

He has no family history of bipolar illness and these facts seem to point toward SSRI-induced hypomanic-like side effects

However, it is also likely that these ominous “SSRI side effects” are likely signs of pre-bipolar disorder emergence, a bipolar prodrome, also known as “pre-bipolaring”

He is currently drug and alcohol free while euthymic

Further investigation

Is there anything else you would especially like to know with regard to treating this patient?

Are there any bipolar II approved medications?

• – No

Are there any well-established guidelines specifically to help in these situations of pre-bipolaring?

• – No

Are some antidepressants safer with regard to lower risk of hypomanic escalation?

• – Yes, SSRI and NDRI (bupropion) antidepressants seem safer than TCA, MAOI, and possibly SNRI classes

Some studies suggest that SSRI may work as well as lithium stabilization in bipolar II patients

• – However, this may be at odds with the fact that antidepressants are felt to allow patients to worsen from bipolar II to bipolar I disorder more often, or convert patients to mixed features or rapid cycling specifiers