Jayani Mahadevan, India

What aspects of bipolar care do you think could be improved by the application of a clinical-staging approach?

I know in the clinical practice that we have, you get a lot of softer versions of bipolar disorder, some of which I’m fairly ambivalent about treating. Obviously bipolar I and bipolar II are fairly well-characterised and I think that in terms of extending that spectrum, I don’t know whether we are including a lot of people who wouldn’t actually require treatment and bringing them into the fold of psychiatry, which I’m not always for. Regardless, it is a very interesting concept.

Based on your experience, what particular signs and symptoms characterise an early-stage patient suffering mania with depressive symtomps?

Like they’ve done in the DSM-5 currently, a lot of non-specific symptoms. For example, anxiety is something that we see a lot in our clinical practice, in people with bipolar disorder. I’m talking about non-specific anxiety symptoms which we see, that are quite frequent in early relapses. It’s a difficult issue to treat and is something that’s a matter of great concern because it’s a very distressing symptom and our current mood stabilisers don’t really address it adequately. It’s a very delicate balance and as a young psychiatrist I feel I don’t have enough experience, but this is what I have come across.

In a person who has got a mixed state, the kind of symptoms you want to look out for would be things like agitated depression, increased psychomotor activity, a great amount of psychological distress. Suicidality obviously is something you would like to consider, and it can be present in fairly early stages as well because you have the combination of increased psychomotor activity along with the psychological distress and the depressive cognition.

In what ways do you believe that clinically validated tools could help identify these early-stage mania with depressive symptoms patients?

I personally don’t have much experience in using clinically-validated tools. We do use rating scales and things like that. We don’t use structured clinical interviews as much in our practice in India; identification is based more on clinical experience. But I think that yes, obviously, having a set of symptoms that you would like to look out for would be a good guide for clinicians.

What is your opinion on personalized medicine and its role in the future of psychiatry?

I’m very ‘for’ personalized medicine and personalized psychiatry. In a sense, psychiatry traditionally has been personalized. If you look at early psychiatry and psychotherapies, those were all very individualized and tailored to a particular patient for his particular needs. So in a sense, you are actually coming from that and then you’ve gone into a broader field and things have become generic and now we are looking at it on a different paradigm. Initially you were talking about psychological factors, now you’ve moved onto neurobiology and genetics.

Our understanding of psychiatric illness is still fairly limited, even genetically. There are great strides that are hopefully going to be made in the next 20-25 years. The idea that you could actually give a person a medication, or you would be able to find vulnerabilities is very exciting. It’s not only genetics, personalization of medicine would involve a whole lot of other factors, so it shouldn’t be that in a blaze of technology and neurobiology. You kind of lose out on the fact that psychiatry is, in the end, about understanding a patient. You shouldn’t lose out on that, saying “okay, he’s just a bunch of genes or a brain” and in that way, I’m fairly traditional.