MHM Magazine

likelihood that you are dealing with a bipolar disorder rather than a unipolar depression. W orse or “wired” when taking antidepressants, which includes failed trials and switching antidepressants H ypomania or hyperthymic temperament I rritability and mixed features during the presenting episode of Depression P sychomotor retardation Loaded family history of B ipolar Disorder Abrupt onset and/or termination of depressive bouts S easonal or postpartum pattern of depression H yperphagia and hypersomnia Early age at the onset of depression (younger than 25 years) D elusions, hallucinations, or other psychotic features, which are more present in Bipolar Disorder Management The management of bipolar depression ascribes to general principles and assessment of medication status: • A risk assessment determines if the patient needs in or out-patient care. • Laboratory investigations are often needed, if not recently done to exclude any medical causes of depression and substance use. • Recent discontinuation of psychotropics medication and response to previous medications • Consideration of Electroconvulsive Therapy (ECT) – specifically in those who are a high suicide risk, present with psychotic depression, or are catatonic Treatment options for bipolar depression are various. Pharmacological treatments include mood stabilisers, antipsychotics, and antidepressants, while non- pharmacological treatments include lifestyle changes, sleep hygiene, light therapy, and psychotherapy. Pharmacotherapeutic agents in monotherapy include Quetiapine at 300 – 600mg (although evidence exists for efficacy at 150mg and above), Lithium at a target of 0.8 – 1.2meq/l, and Lamotrigine at a target of over 200mg (with a need to titrate slowly 25mg every two weeks), Carbamazepine, Olanzapine and Fluoxetine, and Valproate. Please see the South African Psychiatry Guidelines or EMGuidance for more information – link to bipolar guidelines. https://sajp.org.za/ index.php/sajp/article/view/942 .The consensus is that if a patient is depressed on an antidepressant, switch or stop the antidepressant by tapering or cross-titrating. Quetiapine is generally well- tolerated and is effective in preventing depression during maintenance treatment. It has a rapid onset of action and is also suitable for treatment for mixed Episodes. Like all atypical antipsychotics, side effects, specifically metabolic ones, must be closely monitored (specifically weight gain). Lithium is effective in its treatment of acute bipolar depression and prevention of mood episodes, not to mention its efficacy in treating mania. It is considered a first-line agent for treating bipolar depression and is ranked at Level 2 for efficacy. Lamotrigine is also rated at Level 2 for efficacy in treating acute bipolar depression. It is a first-line treatment option due to its demonstrated efficacy in maintenance treatment and tolerability profile. It is effective in combination with Lithium and Quetiapine for treating bipolar depression. The concern with using Lamotrigine is the need for a slow taper upwards, making it unsuitable as a monotherapy in severely depressed individuals. Agents not recommended for treating bipolar depression are antidepressant monotherapy, Aripiprazole monotherapy, Ziprasidone monotherapy, Gabapentin, and Risperidone. The International Society for Bipolar Disorders (ISBD) Antidepressant Task Force has guidelines for prescribing antidepressants for bipolar depression. Experts agree that practitioners should use antidepressants in bipolar depression with caution. This is especially true for patients who switched to mania or hypomania when previously treated with antidepressants. Considering a low dose of an antidepressant alongside an adequate dose of a mood stabiliser or atypical antipsychotic is an option. It's crucial to weigh each patient's potential risks and benefits when prescribing antidepressants. Moreover, monitoring patients for signs of mania or hypomania is essential, especially in the initial weeks or after adjusting the dosage. If a patient doesn't show improvement after 4-6 weeks, experiences severe side effects, or transitions into mania or hypomania, the antidepressant treatment should be halted. For Bipolar depression, recommended therapeutic approaches include Cognitive Behavioural Therapy (CBT), Family Therapy, and Interpersonal Rhythm Therapy. Patients must receive education about medication adherence, recognising signs of relapse, maintaining sleep hygiene, understanding side effects, identifying stressors and triggers, exercising, joining support groups, maintaining a balanced diet, and seeking family support. Engaging in a collaborative discussion about adherence is crucial, given the approximately 50% non-adherence rate in bipolar disorder. It's essential to understand the reasons for non-adherence, as the repercussions of non-compliance and symptom relapse can be profound. Such setbacks might lead to job losses, academic struggles, substance abuse, family conflicts, debt accumulation, legal issues, risky behaviours, and a deterioration of the disorder itself. Bipolar depression is a complex disorder often misdiagnosed as unipolar depression, leading to delayed and inappropriate treatment. Early recognition and accurate diagnosis are vital to mitigate severe consequences such as suicide attempts. Treatment comprises a blend of pharmacological and non-pharmacological methods, with some agents, like Quetipaine, Lithium and Lamotrigine, emerging as primary options. Patient education and adherence is essential, given the profound repercussions of non- compliance and symptom relapse. References available on request. 10 | MENTAL HEALTH MATTERS | 2023 | Issue 5 MHM