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Mood Disorders

“Switching” of Mood From Depression to Mania With Antidepressants

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Bipolar disorder often presents initially with one or more episodes of major depression, and an episode of mania or hypomania may first occur during treatment with an antidepressant, stimulant, or other agent with mood-elevating effects. Such “switching” of mood into mania, a mixed-state, or psychosis can be dangerous. This switching is particularly prevalent among juveniles and young adults exposed to treatment with an antidepressant or stimulant for a depressive, anxiety, or attention disorder.1 Such pathological shifts of mood and behavior may represent adverse drug actions or a manifestation of undiagnosed bipolar disorder.

DSM-5 now considers that mood elevation with antidepressants justifies the diagnosis of bipolar disorder, whereas earlier editions considered it a drug-induced reaction. Before the development of modern psychopharmacology, distinctions between recurrent unipolar depression and bipolar disorder within a broad “manic-depressive” concept may not have been critical. Currently, however, the diagnostic distinction has considerable clinical significance for prognosis and...

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What Exactly is a Mood Stabilizer?

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Two decades ago, there was 1 drug in the mood stabilizer category: lithium carbonate. Carbamazepine was used in refractory cases and in a small number of specialty clinics. Valproate was entering the scene as a novel and effective mood stabilizer. Since then, it seems that every new anticonvulsant is evaluated for its mood-stabilizing properties. More recently, the atypical antipsychotic drugs have emerged as promising treatments for bipolar disorder, and the evidence supporting their efficacy rivals that of anticonvulsant medications. Other agents, such as calcium-channel blockers, have also been evaluated but have shown little evidence of mood-stabilizing properties. Guidelines for the treatment of bipolar disorder now focus on lithium, a selected number of anticonvulsants and an increasing number of atypical antipsychotic drugs as the principal agents. How does the finding that seemingly disparate classes of medication have a common domain of efficacy shape our definition of what constitutes a “mood stabilizer” and our understanding of their mechanisms of action?...

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