From the Guidelines
The first sign of a manic switch is typically increased energy and decreased need for sleep, often occurring suddenly, as reported in patients with bipolar disorder 1. Patients may report feeling unusually energetic despite sleeping less than usual, which can happen within days of starting or increasing antidepressant medication, particularly in people with bipolar disorder. Other early warning signs include:
- Rapid or pressured speech
- Racing thoughts
- Increased goal-directed activities
- Elevated mood or irritability These symptoms may emerge before full-blown mania develops. Clinicians should monitor patients on antidepressants closely, especially those with bipolar disorder or family history of bipolar disorder. If these early signs appear, immediate consultation with a healthcare provider is essential, as medication adjustments (such as reducing or stopping antidepressants and possibly adding mood stabilizers like lithium, valproate, or atypical antipsychotics) may be necessary to prevent progression to full mania, as suggested by the practice parameter for the assessment and treatment of children and adolescents with bipolar disorder 1. Manic switches occur because antidepressants can overstimulate the brain's reward and arousal systems in vulnerable individuals, disrupting normal mood regulation mechanisms. It is crucial to note that the assessment and treatment of bipolar disorder in children and adolescents should be based on the most recent and highest quality evidence, and the use of mood stabilizers and antipsychotic agents should be carefully considered, as they are commonly used for early-onset bipolar disorder in clinical settings, although none of the agents has been well studied in juveniles 1.
From the Research
Manic Switch Signs
The first sign of manic switch is not explicitly stated in the provided studies. However, the studies suggest that manic switch can occur soon after switching from one antidepressant to another, such as from fluoxetine to mirtazapine 2.
Risk Factors for Manic Switch
Several factors can increase the risk of manic switch, including:
- Mixed depressive features 2
- Use of certain antidepressants, such as tricyclic antidepressants (TCAs) or selective serotonin re-uptake inhibitors (SSRIs) 3
- Bipolar disorder diagnosis, particularly bipolar I disorder 4
- Use of adjunctive antidepressant treatment in bipolar depression 4
Treatment Considerations
When treating bipolar depression, it is essential to consider the risk of manic switch and choose treatments that minimize this risk. Some studies suggest that:
- Olanzapine + fluoxetine and olanzapine may be effective treatments for bipolar depression, but may also increase the risk of manic switch 5
- Quetiapine and lurasidone may be alternative treatment options with a lower risk of manic switch 5, 6
- Mood stabilizers may be preferable to antidepressants in patients with mixed depressive features 2