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?

I speak to my patients and ask them a series of questions such as, “Do you sometimes find yourself being very sad, whether there seems to be reason or not? If so, how often does that seem to be happening recently? Do things seem to get you down very easily? Do you react with more sadness than you might ordinarily? Do you sometimes find your enthusiasm just evaporating suddenly?” If their answers are yes then I encourage my patients to talk to me about it; this would be my standard practice.

What has been your greatest clinical challenge in the past year?

My greatest clinical challenge concerned a patient of mine who had bipolar I disorder and was also a healthcare professional himself. His medical board was convinced that he had a personality disorder but in my view he was just somebody with bipolar illness who, despite compliance with fairly rigorous psychopharmacology, would break through occasionally and become manic. His medical licence was in the balance; that was challenging.