COMMENTARY

Anxiety Symptoms and Treating Depression

Michael R. Liebowitz, MD

Disclosures

March 25, 2004

In This Article

Diagnostic Clarity

Most clinicians are aware of the need to distinguish between bipolar and unipolar disorders when evaluating a depressed patient. However, the evaluation of bipolarity is usually confined to trying to detect a history of bipolar 1 (full mania alternating with depression) or bipolar 2 (hypomania alternating with depression) disorders. Less often is the full bipolar spectrum explored, including extended prior periods of productive high energy that may signal vulnerability to antidepressant-induced mood cycling. This manifests itself clinically as responses to antidepressants that are not sustained, as patients cycle from well to depressed, and back to well again, on a given antidepressant.[1] It must be distinguished from antidepressant "poop out," where the positive effects of a drug are lost and not regained. Many clinicians confuse the two and mistakenly treat antidepressant-induced cycling with additional antidepressants or switches to other drugs with similar mechanisms, which does not rectify the situation. The optimal response in such situations is to see if the patient can be treated without antidepressants; if not, then efforts must be made to use mood-enhancing agents that do not induce cycling, such as lithium or lamotrigine.

Turning to the unipolar depression spectrum, there are a number of useful distinctions that can be made that will enhance a clinician's ability to get good effects with the first antidepressant chosen.

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