Repetitive transcranial magnetic stimulation in bipolar depression: Another puzzle of manic switch?

Bipolar depression is common disorder characterized by substantial comorbidity, mortality, the highest suicide rate among psychiatric illnesses and severe social impairment, but is still often misdiagnosed. The real prevalence of bipolar depression could be much higher than is thought, because the problem of misdiagnosis. A percentage of undiagnosed bipolar patients is especially high in population of treatment resistant depression. These patients are most frequently misdiagnosed as having unipolar depression and treated with anitidepressant monotherapy, that result in worsening of the course of the illness and often lead to rapid cycling. Two independent studies 1, 2 in population of 203 and 250 patients with major depression found 40–49% of bipolar disorder. In 1994, the results of survey of National Depressive and Manic-Depressive Association showed that 73% of 500 bipolar patients were misdiagnosed as having unipolar major depression . Unfortunately, 10 years later the same association survey found that nothing has changed and that 69% of another 600 bipolar patients were misdiagnosed in this period of time . Even when correctly diagnosed, treating bipolar depression can also be challenging, and after many treatment guidelines it is often much more difficult to manage bipolar depression than bipolar mania. In treatment of bipolar depression particularly delicate, often questionable, demanding “art and science”, are treatment resistance (require high doses and combinations of antidepressants) vs risk of manic switch (sometimes happen even with the lowest doses of antidepressants in a first few days of treatment), but also problems of different treatment strategies in acute and maintenance therapy that often result in the problem of polypharmacy.