Mania Risk with Esketamine in Bipolar Disorder

Patient Population and Treatment Considerations

A retrospective review found 58% of youths with bipolar disorder experienced manic symptoms after exposure to mood-elevating agents, most commonly antidepressants, according to the American Academy of Child and Adolescent Psychiatry 1, 2
The American Academy of Child and Adolescent Psychiatry suggests that SSRIs like escitalopram can cause dose-dependent treatment-emergent mania, with symptoms emerging within 1 month of dose escalation 1, 2

Ensure adequate mood stabilization with lithium, valproate, or atypical antipsychotics before considering esketamine, as recommended by clinical guidelines 3
Monitor closely for early signs of activation, including decreased need for sleep, increased energy, racing thoughts, or impulsivity, according to clinical guidelines 3
Maintain therapeutic levels of mood stabilizers, as withdrawal increases relapse risk by over 90%, as noted in clinical guidelines 4

Never use esketamine as monotherapy in bipolar depression; always combine with adequate mood stabilization, as recommended by clinical guidelines 3
Implement structured mood monitoring with validated scales at each visit, and educate patients and families about early warning signs of mood elevation, according to clinical guidelines 4
Have a predetermined plan for managing emergent hypomania (dose reduction, increased mood stabilizer, or discontinuation), as suggested by clinical guidelines 3