Case debrief

Many patients with bipolar disorder present in their teens with depression and anxiety

This patient appears to have had a prodrome in a similar fashion and then experienced two sentinel bipolar events where he was sensitive to SSRI use and became hypomanic

• – These spells were brief, mild, and well circumscribed clinically

• – Both abated with SSRI cessation

As he was a presumed bipolar II patient, there was a relative lack of guidelines, but he was treated with a mood stabilizer that allowed for no hypomania spells for many years

This failed to treat his depression and anxiety fully at times

To treat his remaining symptoms, an antidepressant was added in the presence of a mood stabilizer and maximized with remission of all symptoms for a few years

Unfortunately, as the patient was out of town with a relative lack of observation and social support, his medication non-compliance increased, which apparently caused depression followed by a clear hypomanic episode

Once stabilized, he moved again, and was noncompliant as before, escalating into hypomania and then ultimately mania

This shows the unfortunate progression of bipolar illness toward more cycling and impairment over time

Take-home points

There are no clear treatment guidelines for bipolar II disorder

Clinicians must decide whether they wish to prescribe riskier anti-epilepsy or atypical antipsychotic mood stabilizers similar to treating bipolar I patients, or if they wish to gradually treat with unipolar antidepressants and closely watch for hypomanic escalation

Antidepressant-induced hypomania or mania episodes are likely sentinel bipolar disorder events, more so than just side effects

• – These hypomanias tend to be shorter and less severe than non-antidepressant-induced bipolar II hypomania events

• – Per the DSM-5, antidepressant-induced (hypo)mania episodes are now considered to be bona fide bipolar I and II events

Performance in practice: confessions of a psychopharmacologist

What could have been done better here?

• – The initial, maximized, family collateral support and information gathering dissipated as the patient moved away

  • Non-compliance increased, causing more bipolar cycling

  • Therefore, establishing with a psychiatrist or a psychotherapist at the distant city was suggested but the patient declined

    • Perhaps this should have been more strictly enforced, thus increasing the likelihood of earlier hypomania detection

• – The atypical antipsychotic aripiprazole (Abilify) treats unipolar depression as an augmentation at relatively low doses (2–10 mg/d) and was started low in this case to avoid side effects and because the patient was depressed, not hypomanic

  • Perhaps starting the dose at 15 mg/d or higher per acute mania treatment regulatory instructions would have promoted anti-manic effects and avoided the escalation

  • Perhaps low-dose atypical antipsychotics are, in fact, unipolar antidepressants but without the anti-manic protection afforded to their moderate to high doses