Maura asks…

Hi Dr. Fink. My husband of 30 years has just been diagnosed “possible Lexapro-induced hypomania/possible true BPD” After a very difficult and abusive childhood with alcoholic parents, he has been seasonally depressed as long as I have known him. Usually starting around November, and not clearing until late spring.

Although fully functional, he was having somatic complaints and once, an episode of chest pain severe enough to take himself to the hospital for evaluation. Two years ago, he agreed to begin treatment with our family PMD for his depression and did EXTREMELY well mentally on Zoloft 150 mg. He stayed on Zoloft for a year but reluctantly changed to Lexapro 20 mg. qd, due to severe, unremitting heartburn with the Zoloft.

After about a month on Lexapro, he felt he was “losing ground” in terms of his depression, and asked to be switched back to Zoloft. The heartburn returned just as quickly and he was unable to tolerate that side effect.

Within a month after returning to Lexapro, he was clearly more depressed, but it appeared to be an agitated depression. The PMD suggested that he double the dose of Lexapro, to 40 mg. Initially, this seemed to help briefly, but the agitation increased, and there were additional symptoms… bought a sports car, changed his style of dress, started visiting casinos and eventually, had an affair spanning 4 months that he confessed 2 months after it ended because he said he could not live with himself and the guilt. In 30 years, there has never been anything like this before….

At this time, he finally agreed to see a psychiatrist, who immediately took him off Lexapro, in fact, so rapidly…. (6 days) that he developed severe (autonomic- ever have a husband with hot flashes?? – as well as psychological) withdrawal and had to be restarted on it at a 10 mg dose for a week). He was also started on Lamictal. He is now off the Lexapro taper for 7 days, and up to 100 mg of Lamictal. His behavior is remarkably improved. There are still angry flares, but in response to something real and deserving, and not carried over into other facets of his life.

My question is this: Will we ever know whether this is SSRI induced or true bipolar illness? Will there be some clear sign indicating one way or another?

Thank you for your help.

Dr. Fink replies…

This is a very challenging situation, and one that doesn’t have a clear explanation. If manic symptoms started while your husband was on an antidepressant, the symptoms are considered to be a reaction to the medication and are not to be used to diagnose bipolar disorder. Only the appearance of a spontaneous manic or hypomanic episode – an episode that occurs outside the influence of medications or other substances – should be considered in making a diagnosis.

A response to Lamictal doesn’t really offer any insight, because Lamictal seems to help with recurrent unipolar depression, not just bipolar episodes. Furthermore, because Lamictal does reduce the frequency of cycle – depressed and manic – it may mask the presentation of a manic or hypomanic episode that might otherwise have appeared in the future.

In your husband’s situation, however, drawing a distinction between genuine bipolar disorder and the possibility of medication-induced bipolar is not essential, because either way, your husband needs to be cautious with antidepressants.

Our diagnostic categories are still more descriptive than prescriptive and are ultimately inadequate to fully describe the actual brain disorder. So when a patient’s story is puzzling and doesn’t’ seem to fit into the labeling system that we have created, it is best to be precise in our observations and judicious and systematic planning treatment – focusing on what we are actually seeing rather than trying to make someone’s symptoms fit into an inadequate diagnostic schema.

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SSRI Induced Mania or True Bipolar Disorder? | Bipolar Beat | Help For Depression Blog (November 19, 2010)

    Last reviewed: 18 Nov 2010