Case outcome: first interim follow-up visit three months later

Patient is educated about his presumptive bipolar II diagnosis as a worst case scenario

Instructed to maintain a usual sleep–wake schedule and avoid marked amounts of caffeine or alcohol

Agrees to release information for his family so that there can be better monitoring of his treatment and symptoms between visits

As there are no clear guidelines for treating bipolar II disorder, he is instructed about bipolar I treatment options, and that conservative approaches would consider treating him as if he were a bipolar I patient

This might lower the chance of depressive and hypomanic relapses, and might prevent escalating to a bipolar I diagnosis in the future

He is re-evaluated for DSM-5 mixed features specifier, and he has not yet met the criteria

Question

What is the chance that this presumptive unipolar MDD patient will develop a bipolar disorder, or if he is a presumptive bipolar II patient, that he will worsen and progress to bipolar I disorder?

Not much risk as these are separate disorders

Some risk if we consider him unipolar now, as longitudinal studies suggest that 27% of severely depressed unipolar MDD patients will develop bipolar II and 19% bipolar I disorders, respectively

Some risk if we consider him a bipolar II patient as he may escalate into a bipolar I disorder

Case outcome: first interim follow-up visit three months later (continued)

There is clear risk of escalation from MDD to bipolar II disorder, and also from bipolar II to a full syndromal bipolar I disorder

• – If one were to assume his legal problems were to have resulted from mood elevation symptoms and not his AUD, then he would have enough psychosocial dysfunction to warrant the bipolar I diagnosis now

Several mood stabilizing treatments are offered and initially are refused

Between sessions, he researches the medication options and now asks to start lamotrigine (Lamictal) as it is approved for bipolar maintenance treatment and seems to have “fewer side effects” when compared to other mood stabilizers such as lithium, divalprox (Depakote), olanzapine (Zyprexa), etc.

• – There is less organ damage risk, neuromuscular side-effect risk, and metabolic syndrome risks with lamotrigine

• – He is titrated according to regulatory guidelines to 200 mg/d, over six weeks, to avoid severe rash risks

He misses his one-month appointment but does attend at three months

• – There have been no hypomanic episodes

• – Feels moderately depressed

• – SAD continues at a mild level

• – There are no side effects

He is taking some miscellaneous college higher-level courses and feels the depression is interfering, and requests treatment specifically for this

Question

What would you do next?

Refer for psychotherapy; continue the lamotrigine

Increase lamotrigine in the hope that it will treat his depression and anxiety

Add an antidepressant in the hope that his depression and SAD will improve while minimizing hypomania escalation risk, and while he is mood stabilized

Add a bipolar depression-approved agent such as olanzapine–fluoxetine combination (Symbyax), quetiapine (Seroquel-XR), or lurasidone (Latuda)

Add another mood stabilizer such as lithium to his lamotrigine