The article “Subsyndromal depression: Help your bipolar patients feel better” (Current Psychiatry, August 2008) brought to mind what may seem like a hypothetical question but is one I struggle with every day. What emotions are bipolar patients allowed to feel without necessarily leading to medical intervention?
When a loved one dies is the bipolar patient permitted to feel sad, have no sense of pleasure, become tearful, and have difficulty sleeping and concentrating? An individual who experiences these feelings but is not bipolar would be considered to be grieving—a very natural human emotion. What should we do for a bipolar patient?
I tell my patients that with medication I hope to restore the normal range of emotions that an average, healthy person would feel under similar circumstances, and I would address emotional reactions that clearly are beyond that range, such as suicidality or delusional guilt. Am I misinforming my patient?
Mohamed Dattu, MD
Presto, PA
Dr. Ostacher responds
Dr. Dattu brings up what can be a lifelong dilemma for patients with bipolar disorder and their families and suggests a well-conceived response to those in his care. After suffering through a number of mood episodes, patients often find it hard to judge whether they are experiencing bipolar symptoms or merely having emotions and feelings that are normal and expected. Many of my patients report being traumatized in some way by their episodes, so the appearance of any symptoms—sadness, anxiety, excitement, or insomnia—may make them worried that they will relapse to a new mood episode. Just because a patient has bipolar disorder doesn’t mean that these experiences are pathologic.
Psychiatrists use clinical judgment to decide when to intervene. If functioning becomes significantly impaired, thoughts and risk of self-harm appear, and symptoms persist for months, then intervention—whether changes in medical or psychosocial treatment—probably is necessary.
Michael J. Ostacher, MD, MPH
Assistant professor of psychiatry
Harvard Medical School
Boston