A 24 year old female who meets criteria for a major depressive episode was started on fluoxetine (Prozac) and titrated up to 20mg per day. Her presenting depressive symptoms included: sad mood, hypersomnia, fatigue, poor concentration, and crying spells for 1 month. Her symptoms were and still are impacting her functioning at work. She tolerated a dose of 10mg for 1 week without side effects, but at 20mg per day is now reporting some racing thoughts, physical restlessness, and difficulty initiating sleep. She is not reporting an improvement in her mood and other depressive symptoms. She denies SI. She is in the process of engaging in individual therapy.
Is this evidence of bipolar disorder? What additional information is needed? What is the next step for treatment?
This is not an uncommon scenario. While the antidepressants are good treatments for both depression and anxiety, they can cause problematic and confusing side effects but in some circumstances, they can lead to the unveiling of a bipolar disorder. It is sometimes difficult to tease apart which is happening in a particular case. Confusing side effects of SSRIs include: akathisia (physical internal restlessness), increased anxiety (particularly if the dose is titrated too quickly), and activation (fluoxetine is particularly known for this). It is also not uncommon for an antidepressant to lead to improvement in energy before an improvement in mood, which can be confusing as well for patients and prescribers.
When an antidepressant leads to actual manic or hypomanic symptoms (see Managing Mania and Hypomania), then a concern may arise that the patient might actually have bipolar disorder instead of unipolar depression. It is helpful to be as certain as possible of the diagnosis before fully committing to a diagnosis and treatment action, particularly because the diagnosis can carry a lot of weight and because treatment with a mood stabilizing medication can also have significant side effects.
For situations like this, it would be helpful to find out about: personal past history of depressive symptoms, manic symptoms or hypomanic symptoms; co-morbid drug or alcohol use; previous response to psychotropic medications particularly antidepressant medications; contributing medical history and relevant physical exam and lab studies; and, family history of mood disorders, specifically bipolar disorder and depression.
For this patient, a conservative and appropriate treatment plan would be to discontinue fluoxetine (it can be abruptly discontinued because it has a long half-life and so the risk of discontinuation symptoms is minimal) and reassess the patient’s baseline in terms of mood symptoms, including depressive symptoms, hypomanic symptoms and manic symptoms. Because her original depressive symptoms were in the mild-moderate range, a conservative option would be to pursue individual therapy as the primary treatment while working on determining an accurate diagnosis which could include seeking to obtain a psychiatric consultation. If she were strongly interested in medication, a trial of a different SSRI could be appropriate, with very close monitoring to determine if the same type of reaction occurs. Citalopram (Celexa) or sertraline (Zoloft) would be good options to consider. A start low and slow up-titration strategy would be advisable because that helps to avoid the side effects of akathisia, activation and increased anxiety. If a similar reaction occurs and/or there is strong evidence of bipolar disorder in the patient’s history, then a mood stabilizer should be considered either in lieu of or in conjunction with an antidepressant, possibly one with good evidence for bipolar depression, such as lamotrigine (Lamictal), lurasidone (Latuda) or quetiapine (Seroquel).
The nuances of diagnosing bipolar disorder and pursuing treatment requires careful elicitation of pa patient’s past history and current symptom and efforts to differentiate antidepressant side effects from primary signs and symptoms of a bipolar disorder. Please feel free to call SmartCare PC2 for real time consultation on specific cases.