Professor Eduard Vieta, Professor of Psychiatry

According to the IMPACT of bipolar study, almost two thirds of patients report feelings of depression during a manic episode. How do you identify depressive symptoms when your patient presents with a manic episode?

The IMPACT study clearly showed something which we probably already knew, but we were probably not totally aware of; many patients with mania actually display some symptoms of the opposite pole. This is because mania is actually an enhancement of all emotions, not only the positive ones, but also the negative ones.

Mania is actually a limbic system enhancement, with symptoms that can be euphoric but also depressed, or alternatively switching from one to each other. In my opinion, many patients with mania have depressive symptoms and the best way to identify those is to see the patient on a long term scale. If you only see a patient for a few minutes, you may lose a lot of the details; but if you see patients who are admitted as hospital inpatients for instance, you may see that many of them over the course of a few hours show these euphoric symptoms, then they become irritable and after a few minutes they become depressed. If you look for those symptoms you may find out that many patients who appear to be purely manic actually have some depressive symptoms, such as suicidal thoughts or other symptoms typical of depression.

Ideally it is best to listen but at the same time to provide some focus on the concerns of the patient, because in mania and in mixed episodes many patients may lose track of what they say and start to speak about things that are not necessarily the most important. There is a fine balance between listening while having a very open attitude and trying to focus on the presence of certain symptoms which are important; one of which is suicidal thoughts. You don’t want to miss suicidal thoughts, even in manic patients because they are more frequent than we normally believe and the implications are very important.

My greatest clinical challenge recently has been being able to use the drugs which we believe are best for our patients and to make our managers happy at the same time. In my country we are now facing a huge challenge because in many places some drugs are now being forbidden just because of their cost. So even though this wouldn’t be defined initially as a clinical challenge, it ends up being as such because if your options are restricted, you actually use drugs which are not ideal for your patients. Personally, I feel that this is unacceptable.