Manic/hypomanic switching

An 8-week, open-label study of flexibly dosed quetiapine was conducted in bipolar depression [207 ]. Adverse effects includedsomnolence and manic/hypomanic switching (0.6% at week 4,0.3% at week 8). 

During a hypomanic episode, some patients may be more productive and creative than usual, but 5% to 15% of patients may rapidly switch to a manic episode. 

More controversial is the occurrence of antidepressant-induced mania or hypo-mania. DSM-IV specifically states that manic or hypomanic episodes triggered by antidepressant treatment should not count toward the diagnosis of BPAD. However, clinicians have traditionally viewed antidepressant-induced switching from depression into mania as an unmasking of a preexisting BPAD that had previously been unrecognized and undiagnosed. 

Psychiatric patients Schizophrenic or paranoid patients may exhibit a worsening of psychosis with TCA therapy, and manic-depressive patients may experience a shift to a hypomanic or manic phase this may also occur when switching antidepressants and withdrawing them. In overactive or agitated patients, increased anxiety or agitation may occur. Paranoid delusions, with or without associated hostility, may be exaggerated. Reduction of TCA dosage and concomitant antipsychotic therapy may be necessary. 

The treatment of the major depressive disorders such as unipolar and bipolar depressions was initially considered to be uniform, ffowever, with psychopharmacological advances, it has been demonstrated that the patients with bipolar depression may be partially responsive, at least prophylactically responsive, to lithium therapy, whereas the patients with unipolar depression are not as responsive (Abou-Saleh 1992). In addition, the treatment of depression may contribute through serendipity to the confirmation of a subgroup of patients with a bipolar disorder referred to as bipolar II. These patients, following treatment with antidepressants, will switch over to a hypomanic or fully manic phase resulting from pharmacological mechanisms. Thus, another subgroup of the bipolar disorder may be identified in the future. 

Case Example A 29-year-old woman presented for consultation on referral from a psychiatrist who had seen her in psychodynamically oriented psychotherapy for approximately 10 years. The primary difficulty was intermittent interpersonal strife with fellow workers and supervisors. Thus, although quite competent, she had switched positions frequently because of these difficulties. Her history indicated that she had never experienced a full depressive, hypomanic, or manic episode, but that these problems seemed to coincide with intermittent periods of irritability. As a result, she was placed on a trial of lithium, with therapeutic blood levels. Within several weeks of treatment initiation, her difficulties with fellow coworkers and supervisors ceased, and during 1 year of follow-up, she did not have a recurrence of these problems. 

Some evidence supports the idea that a manic or hypomanic episode may be induced in vulnerable padents by and-depressant medic a dons (Goldberg and Truman, 2003). This phenomenon, known as the switch effect, has been clinically observed in many cases. Some data suggest that dreat-ment with anddepressants, pardcularly those with dual acdon at both norepinephrine and serotonin, may precipitate a manic episode in bipolar padents (Stoner et al., 1999 Shulman et al., 2001 Yuksel et al., 2004). Though widely accepted from a clinical perspecdve, this phenomenon is sdll somewhat con-d oversial from a research perspecdve. 

Hypomania is a less severe form of mania, and by dehnition does not cause a marked impairment in social or occupational functioning, and no delusions or haUucinations are present. " Patients with hypomania often do not seek treatment imtil they have a depressive episode, thus hypomania may not be recognized or reported. Symptoms found in hypomanic episodes are similar to those of cocaine- or antidepressant-induced mood disorders thus the differential diagnosis should rule out any substance-induced or medical conditions that present with elevated mood. Hypomanic states should be closely monitored, because 5% to 15% of patients may rapidly switch to a manic episode." ... 

Another risk of antidepressants in vulnerable patients (particularly those with unrecognized bipolar depression) is switching, sometimes suddenly, from depression to hypomanic or manic excitement, or mixed, dysphoric-agitated, manic-depressive states. To some extent this effect is dose-related and is somewhat more likely in adults treated with tricyclic antidepressants than with serotonin reuptake inhibitors, bupropion, and perhaps with MAO inhibitors. Risk of mania with newer sedating antidepressants, including nefazodone and mirtazapine, also may be relatively low, but some risk of inducing mania can be expected with any treatment that elevates mood, including in children with unsuspected bipolar disorder. 

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