SSRI-Induced Hypomania vs True Bipolar
Patient Presentation
Jennifer K. walks into your office for her 2-week follow-up and you barely recognize her. At her initial visit two weeks ago, she was tearful, spoke slowly, made minimal eye contact, and described months of pervasive sadness, loss of interest in her design work, hypersomnia (sleeping 10-12 hours and still exhausted), poor concentration, and a 15-pound weight gain. You started escitalopram 10mg for moderate recurrent MDD.
Today, she's a different person. She's wearing a bright red blazer, bold earrings, and freshly dyed hair. She sits down, crosses her legs, and starts talking before you've finished your greeting.
"I have to tell you — this medication is a miracle. I don't know why I waited so long. I feel amazing. I'm sleeping like 4 or 5 hours and I wake up completely refreshed. I cleaned out the entire garage at 2 AM last Tuesday. I've started three new freelance design projects — I'm thinking about going independent, actually. My creative energy is through the roof. My husband says I'm a completely different person."
She barely pauses to breathe.
"This is the first time I've felt like myself in years. Please don't change anything."
Before you react to her enthusiasm, note what she just told you:
- Sleep reduced from 10-12 hours to 4-5 hours — and she feels rested (decreased need for sleep, not insomnia)
- 2 AM cleaning projects — increased goal-directed activity at inappropriate hours
- Three new freelance projects simultaneously — grandiose planning and overcommitment
- Pressured speech — rapid, hard to interrupt, voluminous
- "Completely different person" — collateral observation of marked personality change
- Onset: 10 days into SSRI treatment — too fast for a genuine antidepressant response
This is not a normal medication response. This needs careful assessment.