Subsyndromal depression

Mr. W has developed a new relationship but gives high priority to keeping a regular schedule. Before going to sleep most nights, he records his mood in a diary to monitor his progress.

Mr. W may show additional improvement in work performance with continued daily mood monitoring and a regularized routine. The care of most patients with bipolar disorder must be systematically optimized over years, not weeks or months.²⁶ Because medication adherence during well periods is essential, discuss and address adverse effects such as weight gain or urinary symptoms.

Measure treatment response. Effectively managing subsyndromal depression requires medication and appropriate cognitive therapy and psychoeducation to engage patients in behavioral change. Measuring treatment response (Table 3) and managing care based on this information allows you to:

• minimize or eliminate ineffective and harmful treatments
  
• continue effective treatments, whether psychopharmacologic or psychosocial.
  

Table 3

Tools for monitoring subsyndromal symptoms

Encourage patient to keep a daily mood chart, including sleep-wake times
Use standardized depression rating scales to monitor symptom changes: Montgomery Åsberg Depression Rating Scale (MADRS) Hamilton Depression Rating Scale (HAM-D) Quick Inventory of Depressive Symptoms–self-rated version
Use the Structured Clinical Interview for DSM-IV, Mood Module to verify whether or not the patient is in a mood episode
Use the Clinical Global Impression Severity Scale (BP version) as a measure of illness severity
Monitor use of caffeine, nicotine, alcohol, and other drugs of abuse by asking about the frequency and amounts used
Calculate body mass index at each visit to monitor for weight gain

Related resources

• Otto M, Reilly-Harrington N, Kogan JN, Henin A. Managing bipolar disorder: a cognitive behavior treatment program therapist guide (treatments that work). Oxford, UK: Oxford University Press; 2008.
  
• Inventory of Depressive Symptomatology (IDS) and Quick Inventory of Depressive Symptomatology (QIDS). Validity, reliability, administration, and scoring. www.ids-qids.org.
  
• Bipolar Clinic and Research Program, Massachusetts General Hospital. Resources for clinicians and patients, plus links to information on bipolar disorder. www.manicdepressive.org.
  

Drug brand names

• Aripiprazole • Abilify
  
• Carbamazepine • Tegretol
  
• Divalproex • Depakote
  
• Lamotrigine • Lamictal
  
• Lithium • various
  
• Methylphenidate • various
  
• Modafinil • Provigil
  
• Olanzapine • Zyprexa
  
• Olanzapine/fluoxetine • Symbyax
  
• Propranolol • Inderal
  
• Quetiapine • Seroquel
  
• Valproate • Depacon
  
• Venlafaxine • Effexor
  
• Zolpidem • Ambien
  

Disclosure

Dr. Ostacher is a speaker for AstraZeneca, Bristol-Myers Squibb, Eli Lilly and Company, GlaxoSmithKline, and Pfizer Inc.