At the 1998 meeting of the APA in Toronto, I put a question to a distinguished panel of clinicians gathered to present various methods of treating refractory depression. I asked, “When do you consider that you might be dealing with bipolar disorder and treat the patient with a mood stabilizer?”

They had no answer. None of them did.

I have an answer: you consider the diagnosis before you treat in the first place. Many patients who have depression have unrecognized bipolar disorder. Many people with bipolar disorder respond only partially  or not at to antidepressants. They need mood stabilizers to get well.

I grill every patient I see thoroughly for possible hypomanic and sub-hypomanic episodes. Even little ones, brief ones, mild ones will cause me to apply a diagnosis of bipolar disorder and treat the patient with a mood stabilizer. I get great results. In new-to-treatment cases of depression I have found where the depression was part of a bipolar disorder, patients do beautifully on a mood stabilizer.

When you have a patient who has been referred to you because he/she has failed to respond to anti-depressants, think hard about bipolar disorder.

When you have a patient who has been referred to you from an alcohol rehab or methadone treatment program, think hard about bipolar disorder.

Pry carefully into the course of illness. Does the patient have “dysthymia”, never stably depressed? That is a pattern for anticonvulsant-responsive bipolar disorder. Dig for those micro-manic episodes.

We have wonderful treatment options for bipolar disorder.

I distinguish between the classic bipolar disorder, manic depressive illness, and the other forms of bipolar disorder. I still treat manic depressive illness with lithium. But the other forms of bipolar disorder I treat with anticonvulsants.

Your choices for a complete treatment with an anticonvulsant:

Divalproex sodium (Depakote in the US)

Topiramate (Topamax in the US)

Lamotrigine (Lamictal in the US)

Valproic acid (Depakene in the US; Epilim in some other countries) (In New Zealand—where divalproex was not available to ordinary patients—my patients often experienced full remission of symptoms with 200mg TID.)

Carabamazepine and Oxcarbazepine (Tegretol/Carbatrol and Trileptal in the US)

When a patient responds to a mood stabilizer, the patient may not need an antidepressant. A hypnotic might be the only other medication needed.

To sum up, I believe that bipolar disorder should be a not be a diagnosis of exclusion. We should look hard for it. If we get the diagnosis right the first time, our patients will not suffer while their illness continues without effective treatment. If we get the diagnosis right the first time, our patients will be happy sooner. That’s where it’s at for us, isn’t it?

[Note for prescribing physicians—Using lamotrigine requires starting low and going slow. I have found that starting with the pediatric dosing form of 5mg BID and moving up every two weeks can be a practical way to dodge the rash (in my experience psychiatric patients seem to have this side effect more often than neurologic patients seem to). If the rash occurs at 5mg or 10mg BID, patients have simply continued taking lamotrigine at that low dose. Unlike the experience of patients taking adult doses, these patients have had their rashes fade over the course of a month, not to recur. IF YOU ARE A PATIENT reading this, do NOT do ANYTHING without consulting closely with the doctor who prescribed your medication. This page has been published as a communication to doctors, and is not intended to be advice to patients. I do not treat patients over the Internet nor give advice to patients over the Internet. If you are a patient and want some advice aimed at you, look at Dr. Ivan Goldberg’s wonderful website.]
 
  2004-21-31 Now for a contrary opinion.