Evidence-Based Reviews

What to do when your depressed patient develops mania

Current Psychiatry. 2015 October;14(10):29-32,35-40,e6

References

1. Goldberg JF, Garno JL, Callahan AM, et al. Overdiagnosis of bipolar disorder among substance use disorder in patients with mood instability. J Clin Psychiatry. 2008;69(11):1751-1757.
2. Rosa AR, Cruz B, Franco C, et al. Why do clinicians maintain antidepressants in some patients with acute mania? Hints from the European Mania in Bipolar Longitudinal Evaluation of Medication (EMBLEM), a large naturalistic study. J Clin Psychiatry. 2010;71(8):1000-1006.
3. Goldberg JF, Perlis RH, Ghaemi SN, et al. Adjunctive antidepressant use and symptomatic recovery among bipolar depressed patients with concomitant manic symptoms: findings from the STEP-BD. Am J Psychiatry. 2007;164(9):1348-1355.
4. Bowers MB Jr, McKay BG, Mazure CM. Discontinuation of antidepressants in newly admitted psychotic patients. J Neuropsychiatr Clin Neurosci. 2003;15(2):227-230.
5. Perlis RH, Welge JA, Vornik LA, et al. Atypical antipsychotics in the treatment of mania: a meta-analysis of randomized, placebo-controlled trials. J Clin Psychiatry. 2006;67(4):509-516.
6. Geller B, Zimmerman B, Williams M, et al. Bipolar disorder at prospective follow-up of adults who had prepubertal major depressive disorder. Am J Psychiatry. 2001;158(1):125-127.
7. Goldberg JF, Harrow M, Whiteside JE. Risk for bipolar illness in patients initially hospitalized for unipolar depression. Am J Psychiatry. 2001;158(8):1265-1270.
8. Yatham LN, Kauer-Sant’Anna M, Bond DJ, et al. Course and outcome after the first manic episode in patients with bipolar disorder: prospective 12-month data from the Systematic Treatment Optimization Project for Early Mania project. Can J Psychiatry. 2009;54(2):105-112.
9. Chaudron LH, Pies RW. The relationship between postpartum psychosis and bipolar disorder: a review. J Clin Psychiatry 2003;64(11):1284-1292.
10. Sachs GS, Nierenberg AA, Calabrese JR, et al. Effectiveness of adjunctive antidepressant treatment for bipolar depression. N Engl J Med. 2007;356(17):1711-1722.
11. Tohen M, Frank E, Bowden CL, et al. The International Society for Bipolar Disorders (ISBD) Task Force report on the nomenclature of course and outcome in bipolar disorders. Bipolar Disord. 2009;11(15):453-473.
12. Schulze TG, Hedeker D, Zandi P, et al. What is familial about familial bipolar disorder? Resemblance among relatives across a broad spectrum of phenotypic characteristics. Arch Gen Psychiatry. 2006;63(12):1368-1376.
13. Song J, Bergen SE, Kuja-Halkola R, et al. Bipolar disorder and its relation to major psychiatric disorders: a family-based study in the Swedish population. Bipolar Disord. 2015;7(2):184-193.
14. Goes FS, Sadler B, Toolan J, et al. Psychotic features in bipolar and unipolar depression. Bipolar Disord. 2007;9(8):901-906.
15. Fiedorowicz JG, Endicott J, Solomon DA, et al. Course of illness following prospectively observed mania or hypomania in individuals presenting with unipolar depression. Bipolar Disord. 2007;14(6):664-671.
16. Tansey KE, Guipponi M, Domenici E, et al. Genetic susceptibility for bipolar disorder and response to antidepressants in major depressive disorder. Am J Med Genetics B Neuropsychiatr Genet. 2014;165B(1):77-83.
17. Tohen M, Zarate CA Jr, Hennen J, et al. The McLean-Harvard First-Episode Mania Study: prediction of recovery and first recurrence. Am J Psychiatry. 2003;160(12):2099-2107.
18. Suppes T, Dennehy EB, Swann AC, et al. Report of the Texas Consensus Conference Panel on medication treatment of bipolar disorder 2000. J Clin Psychiatry. 2002;63(4):288-299.
19. Keck PE Jr, Perlis RH, Otto MW, et al. The Expert Consensus Guideline Series: treatment of bipolar disorder 2004. Postgrad Med Special Report. 2004:1-120.
20. Goldberg JF, Ghaemi SN. Benefits and limitations of antidepressants and traditional mood stabilizers for treatment of bipolar depression. Bipolar Disord. 2005;7(suppl 5):3-12.
21. Sidor MM, MacQueen GM. Antidepressants for the acute treatment of bipolar depression: a systematic review and meta-analysis. J Clin Psychiatry. 2011;72(2):156-167.
22. MacQueen GM, Trevor Young L, Marriott M, et al. Previous mood state predicts response and switch rates in patients with bipolar depression. Acta Psychiatr Scand. 2002;105(6):414-418.
23. Solomon DA, Leon AC, Coryell WH, et al. Longitudinal course of bipolar I disorder: duration of mood episodes. Arch Gen Psychiatry. 2010;67(4):339-347.
24. Tohen M, Chengappa KN, Suppes T, et al. Relapse prevention in bipolar I disorder: 18-month comparison of olanzapine plus mood stabiliser v. mood stabiliser alone. Br J Psychiatry. 2004;184:337-345.
25. Suppes T, Vieta E, Liu S, et al. Maintenance treatment for patients with bipolar I disorder: results from a North American study of quetiapine in combination with lithium or divalproex (trial 127). Am J Psychiatry. 2009;166(4):476-488.

To minimize risk of relapse, psycho-education should include discussion of:
• psychiatrically deleterious effects of alcohol and illicit drug use
• suicide risk, including what to do in an emergency
• protecting a regular sleep schedule and avoiding sleep deprivation
• the potential for poor medication adherence and management of side effects
• the need for periodic laboratory monitoring, as needed
• the role of adjunctive psychotherapy and effective stress management
• familiarity with symptoms that serve as warning signs, and how to monitor their onset.

Bottom Line
When a patient being treated for depression develops signs of mania or hypomania, stop any antidepressant and consider initiating a mood stabilizer, antipsychotic, or both, to contain and stabilize symptoms. Entertain medical and substance-related causes of mania symptoms, and evaluate and treat as suggested by the patient’s presentation. Long-term drug therapy to prevent recurrence of mania/hypomania, as well as risks and benefits of future exposure to antidepressants, should be decided case by case.

Related Resources
• Proudfoot J, Whitton A, Parker G, et al. Triggers of mania and depression in young adults with bipolar disorder. J Affect Disord. 2012;143(1-3):196-202.
• Stange JP, Sylvia LG, Magalhães PV, et al. Extreme attributions predict transition from depression to mania or hypomania in bipolar disorder. J Psychiatr Res. 2013;47(10):1329-1336.

Drug Brand Names
Albuterol • Proventil, Ventolin
Anastrozole • Arimidex
Aripiprazole • Abilify
Bupropion • Wellbutrin
Carbamazepine • Tegretol
Chloroquine • Aralen
Ciprofloxacin • Cipro
Clarithromycin • Biaxin
Clomiphene • Clomid
Digoxin • Digox, Lanoxin
Divalproex • Depakote
5-Fluorouracil • Carac, Efudex
Human chorionic gonadotropin • Novarel, Pregnyl
Ifosfamide • Ifex
Isoniazid • Nydrazid
Lamotrigine • Lamictal
Letrozole • Femara
Lithium • Eskalith, Lithobid
Lurasidone • Latuda
Mefloquine • Lariam
Olanzapine • Zyprexa
Olanzapine/fluoxetine combination • Symbyax
ramipexole • Mirapex
Procarbazine • Matulane
Quetiapine • Seroquel
Ropinirole • Requip
Rotigotine • Neupro
Venlafaxine • Effexor
Zidovudine • Retrovir

Disclosures
Dr. Goldberg is a consultant to Merck & Co. and Sunovion. He is a member of the speakers’ bureau of AstraZeneca, Janssen, Merck & Co., Takeda and Lundbeck, and Sunovion.

Dr. Ernst reports no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

What to do when your depressed patient develops mania

References

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