A patient with depression was given Imipramine for 2 weeks. Relatives noticed increased excitement, colorful clothes, and increased talking. What is the next step in management?

Discontinue Imipramine and start Valproate

Antipsychotic with Imipramine continued

A patient complains of sadness of mood, increased lethargy, early morning awakening, loss of interest and reports no will to live and hears voices asking her to kill self. What is the diagnosis?

Major depressive disorder plus psychosis

Schizotypal personality disorder

Double depression is seen in:

Major depressive disorder from 2 years

A 30-year-old male was brought for evaluation, with a history of his 3-year-old son's death, 5 months prior, following a car accident. At the time of the accident, the patient was a witness. Since then, he has experienced symptoms of sadness, crying spells, feelings of hopelessness, poor sleep, and poor appetite. He has had suicidal thoughts on two occasions, but has not acted on them. He has not been attending work for the past 5 months. What is the likely diagnosis?

Post-traumatic stress disorder (PTSD)

Adjustment disorder with depressed mood

Which of the following is false about bipolar disorder?

Unipolar mania is more common than bipolar disorder

Genetic factors play important role

Rapid cycling is more common in females

Age of onset is earlier than unipolar depression

Bipolar Disorder: Depressive and Mixed Episodes for INI-CET: High-Yield Psychiatry Lessons

Bipolar Depressive Episodes - The Downward Spiral

Core symptoms mirror Major Depressive Disorder (MDD):
- Persistent low mood, anhedonia.
- Changes in sleep (insomnia/hypersomnia), appetite (↓/↑).
- Fatigue, psychomotor retardation/agitation.
- Difficulty concentrating, feelings of worthlessness, suicidal ideation.
Duration: Symptoms present for at least 2 weeks.
Key differentiator from unipolar depression: History of at least one manic or hypomanic episode.
Often more severe, with ↑ risk of psychosis & suicide attempts than unipolar depression.
Treatment challenges: Antidepressant monotherapy can precipitate mania/hypomania.

⭐ Atypical features (e.g., hypersomnia, hyperphagia, leaden paralysis, mood reactivity) are more common in bipolar depression compared to unipolar depression.

Bipolar Mixed Episodes - The Emotional Storm

Co-occurrence of manic/hypomanic AND depressive symptoms nearly every day during a mood episode.
DSM-5: Specifier "with mixed features" for manic, hypomanic, or depressive episodes.
Presents as emotional turmoil: e.g., high energy with despair, racing thoughts with guilt.
Key features:
- Manic/Hypomanic: Agitation, irritability, distractibility, flight of ideas.
- Depressive: Depressed mood, anhedonia, worthlessness, suicidal ideation.
High risk: ↑ suicide attempts, ↑ substance abuse, poorer prognosis.
Treatment: Mood stabilizers (e.g., valproate), atypical antipsychotics. Avoid antidepressant monotherapy.

⭐ Episodes with mixed features (simultaneous manic/hypomanic and depressive symptoms) are associated with a higher risk of suicide attempts, substance abuse, and poorer treatment response.

Diagnosis & DDx - Spotting the Switch

Primary Goal: Differentiate Bipolar Depression from Unipolar Major Depressive Disorder (MDD).
Key: Meticulous history for any past manic or hypomanic episodes.
- Family history of bipolar disorder also informative.
Screening: Mood Disorder Questionnaire (MDQ) useful.
Mixed Features: Major Depressive Episode (MDE) + ≥3 (hypo)manic symptoms OR Mania/Hypomania + ≥3 depressive symptoms.
DDx: Unipolar MDD, Cyclothymia, Schizoaffective disorder, Substance-induced mood disorder, Mood disorder due to another medical condition.

⭐ A thorough history for past (hypo)manic episodes is crucial in any patient presenting with depression to differentiate bipolar disorder from unipolar depression; tools like the Mood Disorder Questionnaire (MDQ) can aid screening.

Management Principles - Calming the Waves

Goals: Remission, relapse prevention, improved function.
Prioritize mood stabilization when addressing depressive symptoms.

Bipolar Depression:

First-line Pharmacotherapy:
- Quetiapine (monotherapy or adjunct)
- Lurasidone (monotherapy or adjunct with Lithium/Valproate)
- Olanzapine-Fluoxetine Combination (OFC)
- Lamotrigine (slower onset, good for prevention)
- Lithium (less robust for acute depression vs. mania)
Adjunctive: Psychotherapy (CBT, IPSRT, FFT).
Severe/Resistant: ECT.

⭐ Antidepressant monotherapy is generally contraindicated in bipolar depression due to the risk of inducing mania or rapid cycling; if used, it should be in combination with an effective mood stabilizer or atypical antipsychotic.

Mixed Episodes:

Goal: Target both manic & depressive symptoms.
First-line Pharmacotherapy:
- Atypical Antipsychotics (e.g., Olanzapine, Risperidone, Asenapine, Cariprazine)
- Valproate
Avoid: Antidepressant monotherapy (risk: worsens mania/agitation).
Adjunctive: Benzodiazepines (short-term for agitation).
Severe/Resistant: ECT.

High‑Yield Points - ⚡ Biggest Takeaways

Bipolar depression resembles MDD; past mania/hypomania is the key differentiator.

Mixed episodes: concurrent manic and depressive symptoms for at least 1 week, causing marked impairment.

Both states carry a significantly elevated suicide risk.

Antidepressant monotherapy risks inducing mania/hypomania; use with mood stabilizers.

Lamotrigine is effective for bipolar depression; Valproate or atypical antipsychotics (e.g., olanzapine) for mixed episodes.

Lurasidone, Quetiapine, Cariprazine are specific atypical antipsychotics for bipolar I depression.

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Bipolar Disorder: Depressive and Mixed Episodes