Treatment-emergent mania, or TEM, is the onset of bipolar mania in patients who are taking antidepressant drugs. TEM can have a large negative impact in the treatment of bipolar disorder, and so it is important to understand this phenomenon.
In a study published in February’s Journal of American Psychiatry, Mark A. Frye and colleagues looked at 176 adult outpatients taking antidepressants for treatment of bipolar disorder. 85 patients responded successfully to the antidepressants, while 45 did not responded and 46 responded with TEM. The researchers were looking for correlates that could be used to predict TEM.
People with bipolar disorder are prescribed antidepressants because depressive symptoms are three times more likely to appear than manic symptoms during symptomatic periods. Somewhere between 40-50% of patients with bipolar disorder are currently on antidepressants.
According to the study, TEM correlates with minimal manic symptoms at baseline coexisting with full syndromal bipolar depression.
Researchers also used the Young Mania Rating Scale at baseline and found that TEM is associated with increased motor activity, speech, and language thought disorder. The researchers call for a careful examination for these specific symptoms before starting antidepressant treatment. Frye and colleagues note that because most mood stabilizers do not work on depressive symptoms, patients need to work with their health care provider to find suitable alternatives.
I have seen this effect in clients in short-term inpatient settings. Clients find it very disturbing to be in a treatment setting and suddenly develop manic symptoms. It also goes to the heart of a few clinical controversies relating to medical treatment. Medications will often work for a period of time, followed by a period of relapse.
Some claim that this means that drugs are not effective as psychotherapy, or make arguments that psychiatric medications are useless money-makers for drug companies. I’m not the world’s biggest cheerleader for drug companies, but the evidence has been there in front of us for years. A combination of psychotherapy and medication works better than either therapy or medication alone. (If you don’t believe me, see articles here, here, and here). But that doesn’t mean that each treatment is equally effective for each presentation of the same disease.
M. A. Frye, G. Helleman, S. L. McElroy, L. L. Altshuler, D. O. Black, P. E. Keck, W. A. Nolen, R. Kupka, G. S. Leverich, H. Grunze, J. Mintz, R. M. Post, T. Suppes (2009). Correlates of Treatment-Emergent Mania Associated With Antidepressant Treatment in Bipolar Depression American Journal of Psychiatry, 166 (2), 164-172 DOI: 10.1176/appi.ajp.2008.08030322