Educationals

While using antidepressants in the treatment of a depressive episode in patients suffering from manic depressive disorder, a major concern is about the increased risk of developing an antidepressant induced manic episode during the course of the treatment and more frequent episodes when antidepressants are used during the depressive episode. Development of rapid cycling in these patients has also been associated with use of tricyclic antidepressants. Thus the mainstay of the treatment of manic as well as depressive disorder remains mood stabilizers like lithium, carbamazepine and valproate.

Lithium, Carbamazepine and Valproate

Lithium is still the standard and widely used treatment of the depressive episode though some of the therapists may prefer to use carbamzepine or valproate as a first line of treatment depending on their personal experience. Valproate and carbamazepine may also be used as an alternative when the patients do not tolerate the adverse effects of lithium or as an adjuvant to lithium when patients do not show adequate response.

A significant number of patients seem to tolerate valproate better than they tolerate lithium or carbamazepine.

The initial dosage and the dose titration of these mood stabilizers for depressive episodes is similar to its use in the manic episode.

If the patient develops depressive episode when he is already receiving any of the prophylactic mood stabilizers, it is desirable to check the adequacy of the dosage and patient's compliance to these medicines. Increasing the dose to achieve higher blood level may be considered if it is tolerated.

One should also look out for other causes for the symptoms of depression like exposure to a psychologically stressful event, hypothyroidism, use of alcohol or other drugs etc.

Electroconvulsive Therapy (ECT)

When the depressive episode is very severe, patient has active suicidal ideation, or patient has delusions and hallucinations or when patients do not show adequate response to mood stabilizers, one may consider the use of ECT in the treatment of depressive episode in patients suffering from manic depressive disorder.

As mentioned earlier, while a patient is receiving ECT, it may be preferable to either discontinue or reduce the dose of mood stabilizers. Valproate and carbamazepine increase the seizure threshold and thus the patient may not get a seizure when administered ECT, while patients receiving lithium when treated concomitantly with ECT may develop confusion.

ECT is one of the very quick and effective treatments for he depressive episodes of manic depressive disorders.

Antidepressants

As mentioned earlier, use of antidepressants should be avoided as far as possible, in the treatment of depressive episode of manic depressive disorder.

Yet, occasionally, when the patient does not show adequate improvement with mood stabilizers, one may be forced to add antidepressants in these patients.

Specific serotinin re-uptake inhibitors (SSRIs) like fluoxetine or sertraline may be preferable over tricyclic antidepressants (TCA's) like impipramine or amitriptyline as the risk of developing antidepressant induced manic episode seems to be minimal with the use of SSRIs

The use of antidepressants should be restricted to the minimum duration of about 4-6 weeks. It should not be continued for 6-8 months after the improvement as it is usually done in case of major depression or recurrent depression. It should be gradually reduced and discontinued as soon as there is a symptomatic improvement in order to avoid drug-induced manic episode and rapid cycling.

Thyroxine

Apart from it's use in cases of hypothyroidism, thryroxine may also be used to potentiate the effect of antidepressants, even when there is no clinical or laboratory evidence of hypothyroidism.

MAINTENANCE THERAPY

As in manic depressive disorder, patients are at a risk of recurrent episodes of mania or depression, a prophylactic treatment with lithium, carbamazepine or valproate may be considered.

Though it is recommended that in general, prophylactic maintenance therapy is indicated in any patient who has more than one episode, many clinicians may not feel very comfortable putting the patient on long term or probably life time maintenance therapy immediately after the second episode.

If the interval between the first and second episode is quite long of about 8-10 years, it is likely that the third episode may occur after another 6-8 years. Under such circumstances, taking into consideration patient's compliance, cost of the therapy etc. one may not prefer to put the patient on maintenance therapy immediately after the second episode.

For the decision of maintenance therapy, one should take into consideration many factors like the severity of the episodes response to treatment, number of episodes, interval between the episodes, risk of adverse effects and cost of the therapy.