Identifying depressive symptoms in patients with manic symptoms

According to the IMPACT of Bipolar study almost 2/3 of patients report feelings of depression during a manic episode. How do you identify depressive symptoms when your patient presents with manic symptoms?

I think we always have to try and take a holistic approach – it’s easiest if we can discuss that at the time as part of our assessment, ask about depressive symptoms and probe for those directly. I think having prompts to remind us to do that can be very helpful; also to try and use standardised ratings if we can.

Sometimes people are very unwell – they’re not in a state of mind where they can really express depressive symptoms very clearly when they’re at their most unwell so we often then rely on our observations and those of the nursing team to see any signs in the presentation that suggest there are depressive elements there as well.

How do you help a bipolar I patient explain how they’re feeling?

I think one of the key things that we work hard to do is make sure that there’s an atmosphere on the unit which is reasonably calm and supportive. That way, people feel that they’re safe and then they’re able to sit down and give a little bit more of an insight.

I think often when people are very unwell they can be in a real crisis and it can get very stressful and almost confrontational at times. We work very hard to avoid that and make sure we can try and find some shared ground. We look at what their perception is and what their worries are – what’s important to them – and then have that as a sort-of shared starting point. I think that’s very helpful.

It also helps to involve family and carers because if they have concerns or even things they’ve noticed, that can be a starting point for a discussion even when a patient themselves doesn’t have a full insight into what’s happening because of their illness.