Very.
OK, I guess you want more than that for an explanation, right? This is an issue that comes up frequently. Since many of the medications that we use to treat other issues can potentially aggravate an underlying Bipolar Disorder, psychiatrists have been increasingly conservative in their prescribing and more aggressive in probing for latent Bipolar symptoms. Stimulant and non-stimulant medicine for ADHD as well as all of the antidepressants used for depression and anxiety are suspect. The risk is not small. If you precipitate significant symptoms of mania with these medicines, there can be long lasting consequences for the patient and their family. It is reasonable, therefore, to err on the side of caution and use a mood stabilizer even in cases where the patient does not meet threshold criteria for the disorder.
Examples of non-bipolar patients who I would put on a mood stabilizer before treating with the above medicines include:
1) the patient with a family history of Bipolar Disorder. It is easy if mom or dad has a clear diagnosis. But even if there is not a clear diagnosis, but a strong suggestion of bipolar symptoms. This would include symptoms in a sibling as well. If the family member is more distant than the first degree relatives (eg grandparents or aunts/uncles), I would probably not use a mood stabilizer.
2) the patient with one or two symptoms that raises a red flag for me. This is a bit nebulous, I’ll admit, but it goes to the truth that there is still a bit of art to doing good psychiatry. For example, many patient complain of racing thoughts, poor sleep, impulsive behavior, distractibility, and occasional times where there mood is very “up”. It can be difficult to differentiate these symptoms from symptoms of other psychiatric illnesses or, really, just plain life experience (not everything is a psychiatric symptom).
3) Patients who’s past reaction to medication has included bipolar-like symptoms or significant agitation. There has been suggestions put forward of the “Bipolar-III” category which would capture those patients who experience manic symptoms only in the presence of another medication (such as an antidepressant). In these cases, you are playing with fire if you don’t provide protection with a mood stabilizer.
In patients with a true diagnosis of Bipolar Disorder, the recommendation is treatment for life with a mood stabilizer. In the above scenarios, treatment with a mood stabilizer would be limited to the time when they are exposed to the potentially aggravating medication. Once the depression or anxiety situation is addressed or there is a decision to stop an ADHD medication, the mood stabilizer can be withdrawn. I would wait until the patient is free of the other medicine for as long as two or three months before stopping the mood stabilizer to make sure that brain chemistry has time to re-equilibrate from the period of medication use (and to keep it on board in case the medicine needs to be restarted).
–Dan Hartman, MD
