Antidepressant-Induced Psychosis Does Not Change Bipolar II to Bipolar I Diagnosis
The diagnosis should remain Bipolar II disorder, not be changed to Bipolar I, because antidepressant-induced psychosis—even when recurrent—represents substance-induced mood elevation rather than spontaneous mania, and psychotic features during depressive episodes are already compatible with Bipolar II disorder. 1, 2
Diagnostic Framework for This Clinical Scenario
Why This Remains Bipolar II Disorder
Antidepressant-induced mania or hypomania is classified as substance-induced per DSM-IV-TR criteria, which means these episodes do not count toward establishing a diagnosis of Bipolar I disorder 1
The American Academy of Child and Adolescent Psychiatry explicitly identifies antidepressant-induced mania/hypomania as a critical warning sign of underlying bipolar disorder vulnerability, but this represents medication-triggered episodes rather than spontaneous manic episodes required for Bipolar I diagnosis 2
Bipolar II disorder is defined as periods of major depression combined with hypomania, explicitly excluding full manic or mixed episodes 1—and substance-induced episodes do not qualify as spontaneous manic episodes
Understanding Psychotic Features in Bipolar II
Psychotic symptoms in Bipolar II disorder are allowed by definition only during depressive episodes, with prevalence ranging from 3% to 45% 3
When psychotic features occur during depression in Bipolar II patients, the diagnosis remains Bipolar II disorder with psychotic features (during the depressive episode), not Bipolar I 3, 4
The presence of psychotic features during imipramine-induced or other antidepressant-induced episodes suggests more severe substance-induced reactions, but does not constitute spontaneous mania 1, 2
Clinical Implications of This Patient's Presentation
Risk Profile Indicators
Antidepressant-induced mania/hypomania occurs in approximately 7.1% of Bipolar II patients in acute trials and 13.9% in maintenance studies 5
The risk of antidepressant-associated mood elevations in Bipolar II is intermediate between Bipolar I (14.2% acute, 23.4% maintenance) and major depressive disorder (1.5% acute, 6.0% maintenance) 5
Multiple antidepressant-induced psychotic episodes indicate high vulnerability to antidepressant destabilization and represent a contraindication to future antidepressant monotherapy 2, 5
Prognostic Considerations
Bipolar II patients with history of psychotic symptoms show higher number of hospitalizations than non-psychotic Bipolar II patients 3
Melancholic and catatonic features are significantly more frequent in psychotic Bipolar II patients, suggesting this may represent a distinct phenotype 3
Psychotic Bipolar II patients are older at presentation but less likely to have family history of bipolar illness compared to non-psychotic Bipolar II 3
Critical Management Pitfalls to Avoid
Antidepressant Use
This patient should not receive antidepressant monotherapy given the history of multiple antidepressant-induced psychotic episodes 2, 5
If antidepressants are considered at all, they must be combined with mood stabilizers, though avoidance may be the safest approach 1, 5
Correct Diagnostic Terminology
The appropriate diagnosis is "Bipolar II disorder" with notation of psychotic features during depressive episodes 3, 4
Do not diagnose as "Bipolar I disorder" unless the patient experiences a spontaneous (non-substance-induced) manic episode lasting at least 7 days or requiring hospitalization 1
The specifier "with psychotic features" applies to individual episodes (depressive episodes in this case), not to the overall bipolar disorder diagnosis 3, 6
Treatment Selection
Lithium monotherapy shows better response in non-psychotic Bipolar II patients 7, suggesting this patient with psychotic features may require combination therapy
Mood stabilizers (lithium, valproate) or second-generation antipsychotics (quetiapine, olanzapine, aripiprazole) are appropriate for both hypomania prevention and depressive episode treatment 4