Clinical Dilemna

[prominence]

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Here is the scenario: I recently inherited a patient with documented bipolar depression in the chart, from a staff member (actually a nurse practicioner) who recently retired. The pt is not on any mood stabilizer presently, stating that there SSRI & Trazadone are sufficient, and refuses to go back to any mood stabilizer because the pt feels the regimen above have maintained their mood just fine. The retired clinician has maintained the above regimen for months now, and wrote the dx as bopilar depression in remission. I maintained the meds as above presently despite trying to convince the pt otherwise, and clearly documented the details of the visit, and then scheduled the pt to come back in 2 weeks for the time being. I asked the pt to stringly re-consider her position, and let me know their decision at the next appt. How would you handle this pt moving forward?

Would you continue to see the pt and maintain the above regimen, but document that the pt refuses any mood stabilizer and is aware of risk of the SSRI precipitating mania?

Or would you state at the next visit that you cannot treat the pt in this scenario without a mood stabilizer on board (the option that feels correct to me), but the clinic would assist her in finding a new psychiatrist to f/u with?

 

[sunlioness]

Are you sure the patient actually has bipolar disorder? I'd make sure the original diagnosis is actually correct before insisting on any changes in an otherwise stable patient.

 

[billypilgrim37]

Educate, document, sleep well at night.

 

[strangeglove]

Agree with the suggestion of really probing the history of mania.

Also, though there is a notion out there that bipolar depression should not be treated with antidepressants because of the increased risk of manic switching (risk is supposedly greatest for TCS's>SNRI's>SSRI>buproprion), my understanding is that this notion remains somewhat controversial, and that the rates of switching are not that much lower if a mood stabilizer or antipsychotic is added. More importantly, bipolar depression is pretty hard to treat, compared to unipolar depression. So, if this patient is getting some benefit from an SSRI + Trazodone, then why not continue this regimen (i.e. if it isn't broken, don't fix it)? You can just see this patient more frequently and watch out for manic switching, and then start a mood stabilizer as needed. I agree that you should inform about the risk of manic switching, but I also think it is not entirely evidence-based to tell patients that adding a mood stabilizer would be that effective in keeping this from happening.

 

[nancysinatra]

You haven't said anything about what manic symptoms or history this patient actually has. Just because such a history was "documented" doesn't mean it was properly taken or was accurate. The patient feels fine and appears to be stable which ought to figure into your current assessment at least somewhat. Please take a proper history, reassess, obtain collateral, and then people on this board can give you their thoughts about what they'd do in this situation.

 

[billypilgrim37]

If I remember the Step-BD paper that dealt with antidepressant induced mania, I think most of the risks were with addition of or increases in dose of the antidepressant. The risk of maintaining someone on an antidepressant regimen with no changes in dose or agent I think was essentially not increased over placebo. But it's been two years since I've read that paper, so who knows.