A female patient with history of depression came to the OPD and was prescribed imipramine. One week later, bystanders complained that she was having excessive talk and increased activity. What will you advice on follow up?*
a. Stop the current antidepressant
b. Mood stabilizer
c. Add sodium Valproate to antidepressant
d. Add antipsychotic
First Step Would be to Stop the Current Antidepressant
•Tricyclics can induce a switch to mania or hypomania in vulnerable
individuals (likely possibility from above available history)
•Other side effects of tricyclics – anticholinergic side effects, delirium, tachycardia, prolonged QT interval, orthostatic hypotension (most common CVS adverse effect, sedation
Treatment Guidelines for Bipolar disorder
•Comprehensive assessment (both medical and substance abuse)
•Discontinue antidepressant (if patient exhibits hypomanic or manic symptoms)
•Choice of treatment setting
•Choice of medications (based on type and severity of current and past episodes, type of polarity, past treatment response)
•Use of ECT when indicated.
•Lithium – Drug of choice in Bipolar I, acute mania and prevention of relapse of both mania and depression
•Valproate – Drug of choice for mixed episodes, Bipolar II, rapid cycling bipolar and comorbid substance abuse
•Treatment of bipolar depression – Lithium, Lamotrigine, Quetiapine, In the above case, stop antidepressant, consider starting a mood stabilizer.