mood D/O classification question

[littlepurplepil]

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So I'm currently in the midst of studying for Step 2 (I'm taking it next Friday! Someone shoot me!! ) and was reading about mood disorders and came across the age-old question (at least for me): If a pt is given an antidepressant for MDD and subsequently develops a manic episode, is that now Bipolar I or Substance-Induced Mood Disorder? It seems to me that the person would be better off classified as Bipolar I, but in my reading it looks like anytime a substance is related to a change in mood, it becomes a substance-induced disorder.


Help me clear up my confusion, oh wise ones 😀

 

[outofhere]

Bipolar type III: Antidepressant induced. DSM only recognizes two types of BAD, but the literature discusses more kinds, such as the above case.

 

[OldPsychDoc]

Bipolar type III: Antidepressant induced. DSM only recognizes two types of BAD, but the literature discusses more kinds, such as the above case.

However, the OP is talking about taking step II, so the "correct" answer will be substance-induced mood disorder, as the "direct effects of a substance" clause applies IN THIS CASE.

 

[whopper]

I'd go with the above.

I had a strange USMLE problem. In my class I was one of the best rated psychiatry students. I did one of the best in terms of scores etc.

but in my USMLE2; I got obliterrated in my scoring for Psychiatry-putting me in one of the lowest tiers for that area. The only theory I could come up with was that I knew too much and started questioning the questions too much. Strangely I did best on my Pulmonogy section and I felt that was an area I was not well prepared putting me in one of the best tiers for that.

Anyways, the USMLE answer is probably the above, but in reality---

It could be antidepressant induced. SNRIs tend to do it more than SSRIs. The theory is the more pathways involved, the more likely it'll put you into mania. E.g. TCAs more so than SNRIs more so than SSRIs (just to inform you I heard this anecdotally but I did read studies confirming that effexor (an SNRI) does it more often than SSRIs).

However, strangely, Welbutrin does it much less often than any of the above and it works on 3 known pathways (Dopamine, Norepinephrine & serotonin).

If I had a pt who was induced into mania due to an antidepressand & that patiient was diagnosed with MDD, I would consider that perhaps the MDD was a misdiagnosis. Its possble. But it after looking into it and confirming it with collateral information that the patient never had a previous manic episode, and ruling out other causes such as illicit substance use, I would then chalk it up to substance induced mood d/o, in which case I'd try to lower the dose of the antidepressant or switch it to another antidpepressant, possibly Welbutrin (only if its the right choice), because Welbutrin does it much less often compared to the other antidepressants around.


If it did turn out that the pt had a previous manic episode or hypomania, I would change the diagnosis to Bipolar I or II depending on what the previous info turned up then change the pt's medication to a mood stabilizer--probably Lamictal if the pt had more depression than mania because lamictal has some evidence that it pushes people out of depression better than the other mood stabilizers.

 

[Anasazi23]

This is an unfair question to ask on Step II, since the answer is still debated hotly amongst psychiatrists. While one could make a strong argument for SIMD, the more likely scenario is a patient with a latent bipolar II or I diagnosis, who, combined with a presumed bipolar diathesis, manifests bipolar (manic) symptoms with the introduction of an antidepressant. As mentioned, this phenomenon of 'switching' is so common (though literature tries to get us to believe otherwise) that there is an underground so-called "bipolar III" classification used in common psychiatric lexicon.

In short, calling this the "direct effect of a substance," as OPD correctly points out, can be walking a fine line. Though in some ways, that seems the easiest way to classify it at the end of the day.

...."There are no absolutes in medicine."

 

[50960]

Most good psychiatrists in this area would call this a switch, thus bipolar 1,II. Med induced mood d/o'd are more about short-term effects (IE. ETOH -depresson, amphetamine-mania). SSRI induced is a switch to mania...true version.

 

[littlepurplepil]

Thanks for the responses, everyone. I was curious about the "boards correct" answer more than what is really applicable in the real world (gotta love learning multiple "correct" answers depending on who's asking 🙄 ) although it's good to know that there is consideration of more classifers/broader categories in practice.

Okay, back to the books for me....