Expert Tips for Assessing, Diagnosing, and Managing Bipolar Depression

Bipolar depression, while fairly common, can be difficult to diagnose and differentiate in individuals with basic depression. Andrew J. Cutler, MD, Courtesy Assistant Professor, Department of Psychiatry, University of Florida, Gainesville, and CEO and Chief Medical Officer, Florida Clinical Research Center, LLC, began his presentation at the 2013 NEI Psychopharmacology Congress by advising clinicians on how to assess and identify individuals with bipolar depression vs. unipolar depression. According to Cutler, there are several key questions and events clinicians must pay attention to when trying to diagnose bipolar depression.

He noted that the age of onset is particularly telling. A patient who was under the age of 25 when they experienced their first major depressive episode is at 3 to 4 times greater risk of developing bipolar depression than those who experienced their first episode later in life. Additional red flags include the number of depressive episodes (the greater the number, the greater the risk of bipolar depression), the number of hospitalizations, and the length of stay at the hospital.

Furthermore, Cutler advised the audience that a patient who is having mixed depression with 3 or more symptoms of hypomania such as mental overactivity, psychomotor agitation, or talkativeness is also at a greater risk for conversion into bipolar depression. He said that clinicians should also take into account the patient’s family history; patients with a family history of Bipolar I or Biopolar II are also at a higher risk. Cutler advised that clinicians should also suspect bipolar depression if a patient shows psychomotor slowing, hypersomnia, or hyperphagia. He noted the recent DSM-V changes that revised the criteria for a manic episode to include symptoms such as increased energy and increased agitation.

In terms of treatment for bipolar depression, Cutler focused on lurasidone, quetiapine, and olanzapine-fluoxetine (OFC). These three drugs are FDA approved and show the “strongest evidence of efficacy with bipolar depression.” However, Cutler also said that he thinks lurasidone should be the first choice for treatment due to the fact that the low-dose and high-dose symptoms are similar and there are more moderate side effects associated with this drug. With OFC and quetiapine, it is important to note that there is a concern in terms of metabolic problems such as those associated with weight gain.

Cutler touched briefly on the latest recommendations from the International Society of Bipolar Disorders. He said clinicians can consider the use of antidepressants (AD) as “adjunct for acute bipolar I or II depressive episodes in patients with a history of good AD response,” or “as maintenance for patients who relapse into a depressive episode after stopping an AD.” He noted that antidepressants should not be used long-term in patients as this does not prevent relapse. He discussed the positive evidence associated with family therapy involving increased communication and psychoeducation.

In conclusion, he stressed the importance of training patients or friends to monitor for prodromal symptoms such as a “change in motivated activity, sleep cycle, impulsivity, or interpersonal behavior,” as well as giving patients guidelines to address these symptoms in terms of “small medication adjustment, change in daily routine, stress reduction, and increased social interaction.”