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?

You can either be formal and use the DSM-5 mixed specifier definitions, and actually look for depressive symptoms listed there to make a formal diagnosis of a mixed specifier within a manic episode, or you can just basically use clinical wisdom. And there are actually some signs which might hint towards bipolar depression in the background, rather than just the pure mania, and these are signs which are often considered atypical, like for example, extended sleep hours or greater appetite. These can actually be signs of increased agitation, for example, poverty of ideas and thoughts while still manic. There are quite a lot of different symptoms which you might identify in your manic patients and it’s pretty clear, as we know from quite a lot of studies, that the presence of just one depressive symptom while manic will actually change response to treatment. It makes you think twice about what might be the appropriate treatment.

How do you feel about the use of patient self-reported assessment tools and questionnaires in bipolar I disorder?

I’m actually greatly in favour of using self-ratings and self-assessments of patients. For one thing, it gives you a true view of a patient. Secondly, they are reliable in bipolar patients with hypomania; that is to say in patients who actually know how to use the self-rating tool. I personally had very good experiences during my whole clinical career with the life charting method, both the original version on paper but also the automated versions which you can run on your laptop or even on your iPhone. It gives you, as a clinician, not only a very clear view about the actual symptoms but also how the patient himself rates them and what his most demanding needs actually are. So I would say it really adds a lot of value to any clinician rating scales.