Dr. Grossi's Blog
A common clinical presentation of a patient in my practice is one of chronic depression starting in early teenage years or even younger and manifesting a pattern of frequent recurrences. Often these people have had forty or even fifty dpisodes of depression over twenty or more years. They have usually been treated with many antidepressants with erratic or downright poor rexsults. Are these individuals suffering from treatment resistant depression (TRD) or bipolar disorder?
How can a psychiatrist differentiate the two conditions and why does misdiagnosis occur so frequently with such tragic and ruinous consequences. There was one study that found that there was a gap of nine and a half years between first presentation in the office and correct diagnosis. Part of the problem, in my view, is overly restrictive diagnostic criteria set out in DSM-IV and its succesor DSM-5. For example DSM-5 requires a hypomanic state to last at least four days and be "present most of the day every day." In my experience most hypomanic states last less than two days and sometimes just six or eight hours. Furthermore DSM-5 sets out severity criteria which many patients fail to meet. Those include grandiosity, decreased need for sleep, racing thoughts, and excess involvement in activities with painful consequences such as buying spres, sexual indescretions, or foolish business decisions. In contrast, many patients characterize these periods as being normal with more activity, productivity, socialization, and motivation. If the psychiatrist misunderstands the significance of these states, it may well lead to a diagnosis of major depression rather that bipolar disorder. Remember, the core pathology in depression is depression but the core pathology in bipolar disordewr is mood gyrations. Complicating the assessment is the patient's propensity to seal over these brief hypomanic states because they are viewed as irrelevant to their psychiatric problems. It is incumbant on the examiner to ask about these states directly both from the patient, family, friend, and spouse.
What are some of the other factors I take imto account in distinguishing unipolar depression from bipolar disorder?
1) Age of onset. Bipolar disorder typically starts before twenty years of age, often in childhood, and with mood swings. I always ask the patient's age when he/she experienced their first depression.
2) Bipolar depressions are frequently brief, develop in a short period of time, have a high recurrence rate, and often have a seasonal pattern.
3) Postpartum onset is common.
4) Response to antidepressants are unpredictable. Sometimes there is no response, other times the response in incredably rapid, sometimes the patiend gets more depressed, sometimes there is a dysphoric response with agitation and insomnia. Medications frequently lose effectiveness quickly in bipolar patients.
5) Family history of bipolar disorder.
6) Bipolar patients often have histories of self-harm, such as cutting which is experienced as relief from tension.
7) High frequency of substance abuse, usually over 50%.
8) ADHD is co-morbid in about 50% of cases.
9) Bipolar depression is atypical,i.e.,oversleeping, tremendous loss of energy, weight gain, and interpeersonal sensitivity. Usually there is also trouble getting up in the morning and pronounced daytime sleepiness. In contrast, unipolar depression is characterized by insomnia, weight loss, agitiation, and typically no complaint of daytime sleepiness.
10) Bipolar patients frequently have vocational problems, romantic problems, fiscal extravagances, multiple marriages, and episodes of promiscuity.
To review, unipolar depression is suggested by later age of onset (after 25), minimal history of mood swings in childhood and adolescence, depressions developing over many months, middle of night awakenings and early morning awakening, usually no complaints of daytime sleepiness, diurnal variation, i.e., worse in AM and improvement during the day or the reverse pattern, depressive pattern is typical, i.e., insomnia, weight loss, and agitation.
Treatment of mood disorder patients includes psychotherapy and pharmacotherapy. There are many types of psychotherapy but the most important point is that forming a relationship characterized by empathy and strong rapport is the most important aspect because it helps the patient listen to the therapist and incorporate him/her into their psychological operations. Mood stabilizers are the foundational pharmacological treatment of bipolar disorders. The six mood stabilizers are lithium, divalproex, carbamazepine, oxcarbazepine, lamogrigine, and zonisamide. In my opinion lithium's side effect burden is greatly overnblown in the literature much of which dates from a time when higher doses were commonly used. It is effective for about 33% of bipolar patients and for them it is the closest thing to a miracle drug available in psychiatry. Divalproex can cause birth defects and weight gain. Carbamazepine has a multitude of drug interactions and lamotrigine must be ramped up slowly because of the possibility of a serious drug rash. It is an alergic phenomena and so must happen at initiation. Once you are on lamotrigine for a few months, you can forget about the rash. Zonisamide should be ramped up slowly at bedtime to avoid side effects. For some reason it seems to work best in adolescents. Second generation antipsychotics (SGA) have mood stabilizing properties as well as antidepressant, anti-manic and antipsychotic properties. They can be helpful in mananging bipolar patients with or without psychosis. They tend to produce weight gain and various metabolic problems.