Likely Diagnosis: Kratom-Induced Mood Disorder vs. Bipolar Disorder
The most likely diagnosis is a kratom-induced mood disorder, given the temporal relationship between kratom use and mood symptoms, though underlying bipolar disorder cannot be definitively ruled out without observing the patient off kratom. 1
Critical Diagnostic Considerations
Kratom as a Primary Confounding Factor
Kratom must be discontinued before making a definitive bipolar diagnosis, as the Society for Perioperative Assessment and Quality Improvement explicitly warns that kratom has both opioid-like and stimulant-like properties that can directly cause mood swings, anxiety, and neurologic effects including seizures. 1
Kratom produces mood lability, anxiety, irritability, and sleep disturbances both during active use and withdrawal, making it impossible to distinguish substance-induced symptoms from an underlying mood disorder while the patient continues use. 2, 3, 4
The American Academy of Child and Adolescent Psychiatry specifies that manic episodes precipitated by mood-elevating substances are characterized as substance-induced per DSM criteria, not as primary bipolar disorder. 1, 5
Distinguishing Substance-Induced from Primary Bipolar Disorder
Key questions to establish the diagnosis:
Temporal relationship: Did mood swings begin only after kratom use started, or were distinct manic/hypomanic episodes present before kratom exposure? 5
Episode characteristics: Does the patient have distinct, spontaneous periods of elevated mood with decreased need for sleep and psychomotor activation, or is the mood lability chronic and reactive? 5
Duration criteria: Have there been clear episodes lasting at least 4 days (hypomania) or 7 days (mania) with marked departure from baseline functioning? 5
Family history: Is there a family psychiatric history of bipolar disorder or other mood disorders? 5
Clinical Algorithm for This Patient
Step 1: Immediate Assessment
Obtain detailed kratom use history: daily dose (noting if >5-15g/day, which increases withdrawal risk), duration of use, temporal relationship to mood symptoms. 1, 2
Screen for other substances via toxicology, as kratom can cause false-positive opioid results. 3
Document whether mood symptoms existed before kratom use or only emerged during/after use. 5
Step 2: Kratom Discontinuation
Kratom must be discontinued to clarify the diagnosis, as the Society for Perioperative Assessment and Quality Improvement does not recommend use of this supplement. 1
Consider buprenorphine-naloxone for kratom withdrawal if the patient is using high doses (>5-15g daily), as multiple case reports demonstrate successful treatment of kratom use disorder with this approach. 2, 6
Monitor for withdrawal symptoms (anxiety, irritability, mood changes, insomnia) which can persist for weeks and mimic mood disorders. 4
Step 3: Observation Period Off Kratom
Observe for at least 2-4 weeks after kratom discontinuation before making a definitive bipolar diagnosis, as kratom-induced symptoms can persist during this period. 4
Use a life chart to prospectively track mood patterns, sleep changes, energy levels, and functional impairment during this observation period. 5
Look specifically for distinct episodes of elevated mood with decreased need for sleep (not just insomnia), increased goal-directed activity, and marked departure from baseline. 5
Step 4: Diagnostic Clarification
If after kratom discontinuation the patient demonstrates:
- Clear episodic pattern with distinct periods of elevated/irritable mood lasting ≥4-7 days with associated symptoms (decreased sleep need, increased activity, impulsivity): Consider bipolar disorder. 5, 7
- Chronic, persistent mood lability without distinct episodes: More consistent with personality factors, trauma-related symptoms, or residual kratom effects. 1
- Complete symptom resolution: Confirms kratom-induced mood disorder. 1, 4
Management During Diagnostic Clarification
Avoid Premature Bipolar Treatment
Do not initiate mood stabilizers or antipsychotics until kratom is discontinued and the clinical picture clarifies, as these medications carry significant side effects and the diagnosis remains uncertain. 1
The American Academy of Child and Adolescent Psychiatry notes that mood stabilizers are often used for mood lability and explosive outbursts, but the specificity of treatment response is unclear when the underlying diagnosis is uncertain. 1
Symptomatic Management
Address anxiety and sleep disturbance with non-pharmacologic interventions first: breathing techniques, progressive muscle relaxation, grounding strategies, mindfulness, and regular cardiovascular exercise. 8
If pharmacologic intervention is necessary during the observation period, consider short-term anxiolytics rather than mood stabilizers, but note that benzodiazepines may cause disinhibition. 1
Avoid antidepressants during this diagnostic clarification period, as they can precipitate manic episodes if bipolar disorder is present, and kratom already has serotonergic effects that could lead to serotonin syndrome. 1, 9
Critical Pitfalls to Avoid
Never diagnose bipolar disorder while the patient is actively using kratom, as the substance directly causes the presenting symptoms. 1, 5
Do not rely solely on a previous provider's suggestion of bipolar disorder without documented evidence of distinct manic/hypomanic episodes meeting DSM duration and severity criteria. 5
The patient's denial of depression is not diagnostically useful, as bipolar disorder can present with predominantly manic symptoms, and patients often lack insight during mood episodes. 5
Beware of polypharmacy: if kratom use continues, adding psychiatric medications increases risk of drug interactions, as kratom inhibits CYP3A4, 2C9, 2D6, and 1A2. 9
Follow-Up Strategy
Schedule close follow-up visits (weekly initially) to observe symptom evolution after kratom discontinuation. 5
Obtain collateral information from family members who can describe behavioral changes and episodic patterns more objectively. 5
Reassess diagnosis periodically, as the clinical picture may evolve over time, and what initially appears as substance-induced symptoms may reveal an underlying mood disorder. 5
If clear bipolar disorder emerges after kratom discontinuation, lithium is FDA-approved for acute mania and maintenance therapy and has demonstrated anti-suicidal properties. 7