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DIAGNOSIS DETAILS
(major revision 9/2007) 
(Ukrainian translation, from a reader; I can't vouch for it as I can't back-translate it, and Google-Translation can't very well either but it looks on target best as I can tell) 

Types of depression

Bipolar variations

Why does this happen?


What kinds of depression are there?

You will run into many adjectives describing depression. Here are some of the most common variations:

  • acute or chronic
  • situational or unprovoked
    • ("exogenous" or "endogenous")
  • prolonged grief
  • due to medical condition
  • atypical

"Acute" means severe, and generally also means sudden, implying that prior to this severe depression the person was much less depressed, perhaps not at all. The opposite is "chronic", meaning the person has had this for years. The usual DSM term for this is "dysthymia" (technically, depressed more days than not, for more than two years).

Situational depressions have clear causes (or at least people think there is such a connection).  Unprovoked, or "endogenous" depressions come "out of the blue": no clear event is associated with the start. Some people will call this "chemical" depression, meaning there was an internal cause, not an external one.

Most people experience sadness when they lose something to which they were emotionally attached. When the loss is great, such as the death of a family member, people can experience a deep grief. In many respects this looks like "depression", but most people will feel themselves gradually coming out of it, starting within a few days or sometimes a week or two. Grief that continues beyond about 1 month is generally considered "prolonged" and may need some help to resolve.

Depression can be associated with medical conditions. Strokes and Parkinson’s disease are among the most common such causes, but several common medications, and many other diseases (problems with the immune system , heart, and especially hormones such as thyroid) can be associated with depression. The list is so long that "ruling out" all these other diseases is very impractical. You can end up with a lot of tests that are painful and even carry some risk, such as a heart catheterization or using a scope to examine your stomach or intestines. After a blood test looking at least at thyroid function, it is not routine to go looking for potential medical causes for depression. Rather, the doctor looks for signs and symptoms of these illnesses to see if they might be the cause. Without such signs and symptoms, it is very unlikely that there is some "medical" basis for your depression.

Finally, in this brief survey, there is "atypical depression". Technically this refers to a group of patients who have depressive symptoms but also have other features: "mood reactivity" (intense emotional reactions), and sleeping too much and/or eating too much, thus gaining weight. This symptom complex has been shown to identify a group of people who respond better to an MAOI (monoamine oxidase inhibitor) than to imipramine, another older antidepressant. Other symptoms associated with the "atypical" label include "leaden paralysis" (extreme lack of energy), and "rejection sensitivity" (over-sensitive to perceived slights), although these were recently shown not to predict imipramine non-response as well.Sotsky  All these symptoms have tremendous overlap with bipolar symptoms.  In fact, interpersonal sensitivity is specifically associated with bipolar II.Benazzi   Moreover, bipolar disorder tends not to respond well to the older antidepressants, and may respond best to the MAOI’s. Are these really different diseases, or just different aspects of a complex syndrome? If a person does well on an MAOI, great. If the response is not enough, or fades away, consider bipolar disorder as an alternative explanation for this symptom pattern.

What types don’t get better?

As saw in the last section, there is a group of patients with depression who do not get better with standard treatment, and so are called "treatment resistant". Some of these people have depression that may eventually respond to the right combination of psychotherapy and medications, and actually have difficult versions of "unipolar depression". Could you be one of those? How long should you go on trying antidepressants and/or therapy?

There is no standard answer to this question. The simple answer is: read this site and if you think "bipolar" might explain your history, consider trying mood stabilizers. If you already have tried them, and didn’t improve, were you taking an antidepressant at the time? Antidepressants can make bipolar disorder worse and keep mood stabilizers from being effective — my opinion. You should read the appendix "Do I really have to stop my antidepressant?".

But what if you’ve tried 3 or more antidepressants and several therapists? And you don’t drink alcohol, which you may have already learned to avoid.  If you have a mood disorder this complex — what then? You could have something more like Borderline Personality Disorder.Goldberg(a)

There are surely other reasons to have a treatment resistant depression, which hopefully we will understand further soon. This includes influences of other illnesses such as stroke or Parkinson’s disease; immune disorders such as lupus erythematosus; cardiac problems like congestive heart failure, and so forth. There is growing research on the effect of reproductive hormones on mood, that may explain some women’s mood experience.

However, at present, eventually "treatment resistance" boils down to these two options:

  1. more antidepressant trials
  2. reconsider psychotherapy (some, more, different type)

Recent research in psychotherapy has shown that two types of psychotherapy -- interpersonal and cognitive/behavioral therapy — work as well as medications in mild to moderate depression, possibly with greater long term effectiveness.Frank and Thase. But eventually, after multiple trials of medications and therapy, what then? Long before then, one should apply an old rule of medicine: if the patient does not respond to a routine treatment, always reconsider the diagnosis. Has something previously been ruled out that now needs to be reconsidered? Has something been omitted previously that should now be included?

People with treatment resistant depression may get better with mood stabilizers (discussed in detail below). Mood stabilizers may also be useful in multiple other conditions related to mood disorders, including: impulse control disorders, borderline personality disorder, premenstrual syndrome, irritable bowel syndrome, migraine, dissociative disorder, and as add-on medication in unipolar depression. Getting better on one of these medications doesn’t mean you have bipolar disorder, but by then the label doesn’t matter as much.

This kind of thinking leads to an argument that mood stabilizers are being used too widely, or that the bipolar concept is being stretched too far.Sobo The best response to this concern is simply to read the main references on this issue by mood specialistsFreeman; McElroy; Perugi; Angst; Akiskal ; Akiskal and Pinto; Goodwin; Fawcett; Jamison For my personal response to this concern, read the appendix "Stretching the Diagnosis Too Far"? a Bipolar "Bandwagon"?

What if anxiety is a big part of the problem? (revised Sept 2002)

Anxiety is clearly associated with bipolar disorder.  If you have anxiety, or if you're a skeptic about this concept, I hope you'll read my extensive, referenced essay on this topic (moved to a separate section because of it's importance and the need to write frequent updates).  

Can kids have bipolar disorder? What does that look like? 

We know this is a genetic disorder.  So anyone who has this illness is going to wonder if their kids (born or yet to be created) could get it.  If the current view that early treatment can decrease an entire lifetime of symptoms holds up, detecting early signs of the illness will be crucial.  So this question of how bipolar disorders show up in kids is crucial too.  

Unfortunately, the "diagnosis" puzzle is even harder in kids than it is in adults.  But, as one researcher put it, the most important step in diagnosing bipolar disorder is to suspect it in the first place.  The worst error is not to consider it.  Even if the diagnosis is held back until it is fairly certain, that's better than missing it entirely, which is the case all too often.  

As you may have seen from this site, making the diagnosis in adults is hard enough. Making a diagnosis of bipolar disorder in children is much, much harder.  I will offer you two views on this.  One is from a website devoted to the issue of bipolar disorder in children; and one is from a very experienced psychiatrist who worries that bipolar disorder is being overdiagnosed in children (as well as adults).  You should read both to make sure you're getting a balanced view. Since Dr. Sobo's view is easily drowned out these days (the make-the-diagnosis view has pharmaceutical companies behind it, for example), start with his warning.  

Then try a website to help parents with their worries as they watch their children grow up and wonder about whether they might have bipolar disorder.  It's run by the Child & Adolescent Bipolar Foundation.  It has the full text of an expert summary from 1997 (getting a bit dated now) about how to diagnose and treat kids. See their "About Early Onset Bipolar Disorder" in the Learning Center as a start, but go back for their Reference Center as well.  It includes full text of a good collection of articles, many pretty technical, but very well selected: www.bpkids.org . Don't forget the warning from Dr. Sobo. 

Are my kids going to get it? (added Jan. '01) 

That's possible, because it's genetic.  For more on that, see the section below on "what causes bipolar disorder?" and especially the page about genetics.  Ok, if it's genetic, how likely are your kids to get it? 

The answer used to be "roughly 20% chance if 1 parent has it, 50-70% chance if both do".  Those figures apply to Bipolar I data; there has not been separate work on Bipolar II families, though the picture looks roughly the same so far.  

However, thanks to a fine article by Duffy and colleaguesDuffy, there's more to say than that now.  Their article is very technical, so the following is a "translation" into plain english; any errors in translation are mine. 

Here's how that math works, in case you were wondering:  "20%" means that if you had 5 kids, statistically one would have a mood disorder.  If you only had two kids, there would be a bit more than 50% chance that neither of them would be affected, versus a bit less than 50% chance that one would be affected.  

Dr. Duffy and her colleagues emphasize that "20%" is just an average risk, if one parent has bipolar disorder.  From there, you need to take into account how many affected relatives you have.  If there are a lot, the risk to your children is higher; if there aren't very many, then the risk is lower than 20%.  

If you want more details, read the special section on genetics and risk. 

Are we stretching the diagnosis too far? Is this a bipolar "bandwagon"? 
(In revision, 6/2005)

Even some psychiatrists think this bipolar way of thinking has gone too far.Sobo They are concerned that excitement about this diagnosis and the treatment options it opens has become a "bandwagon". Yet, how can we tell the difference between a useful new way of thinking and a bandwagon? Won’t they look similar, perhaps identical, at first? Surely we already know the answer to this puzzle: "the proof is in the pudding"! Patient outcomes will tell us how valuable a new approach really is.

Granted there will be some placebo value initially for almost any "new" treatment that comes along. That’s why data from "open trials" of a new medication (no control group, no blinding of patients or providers) almost always overrate effectiveness. Only later when the controlled trials are done do we get a clearer sense of what the medication offers relative to placebo.  Gabapentin (Neurontin) is a good example of this, now shown to be no better than placebo despite great initial interest and positive results. Indeed, this pattern of initial excitement about a treatment, followed by disappointment, is so common that doctor's have joked about new medications thus: "Use it quick before it stops working!"

Bandwagons aside, if a patient with depression happens also to have irritability, or insomnia, or anxiety - is he/she "bipolar", or is that stretching the diagnosis too far?

First, remember the new "spectrum" way of thinking about this. We should not be asking a black-and-white "bipolar or not?" question. Rather, ask "how much of this bipolar-like trait might be present?"

Secondly, we should think of "diagnosis" in these cases as a heuristic process. I love this term. It describes exactly where we are in this dilemma. Per Webster’s dictionary, heuristic means "valuable for research but unproved or incapable of proof". We let go of the need for certainty in favor of assessing usefulness.

A heuristic approach to this problem asks not "do I really have bipolar disorder?" but rather: "If I try mood stabilizers, what is the likelihood of benefit? What is the likelihood of risk? How effective are the alternatives, and what is the risk they pose?"

A brief trial of valproate presents low risk in people who have normal liver tests. Long-term treatment is different. Weight gain is very common and must be managed cautiously, as there are numerous health risks associated with obesity, and possibly some risk of changes in reproductive hormones in women. 

If weight gain is not going to be a problem because we are going to replace the medication if appetite increase occurs, the remaining risks of valproate are viewed as quite minor by most people (see my valproate basics). Thus even if their symptoms are not severe, people often still conclude that at least a test of the medication will bother them less than continuing their symptoms.

Even if the risks were greater, such as with carbamazepine, many people still conclude the risk is justified because they have reached a stage where "no treatment", or continued trials of antidepressants, or even quality psychotherapy, is far less preferable.

For a similar but more historical and elegant discussion of this "bandwagon" issue, see this essay by Dr. Ghaemi, a research psychiatrist in the Psychopharmacology Program at Cambridge Hospital, and an instructor in psychiatry at Harvard Medical School.  

Normal? mentally ill? Where’s the line between them?
(Updated 6/2005)

In general, people who ask this question are really worried about their own sanity, or about how they will be perceived by others, especially if they are labeled as "bipolar". However, the question should be resisted, in favor of a new "model" of the illness. Again, think in terms of a spectrum, or continuous line. You will remember the "mood spectrum":

A similar spectrum exists, from completely mentally healthy, to severely impaired by mental symptoms. As stated in the milestone document "Mental Health: Report of the Surgeon General" (1999), mental health and mental illness are merely extremes on a continuum:

Mental Health <-----------------------------------> Mental Illness

"Ill" or "healthy" sets up a yes-or-no, black-or-white distinction that is really a problem in bipolar disorder, where people can have long phases with no symptoms. Do they still have a mental illness? Imagine a man who has had a heart attack. Perhaps he has worked hard at physical activity after his attack and no longer has any limitations. Does he have a cardiac illness? What if he instead has no limitations because his medications work very well? Does he still have a cardiac illness? (Perhaps even more to the point, have you ever heard anyone ask those kinds of questions!?) Our society’s tendency to think in black-or-white terms creates this labeling problem.

For example, consider the following headline: "Kinkel unlike the other shooters: mental illness set Springfield teen apart from other youths who terrorized schoolmates". Kip Kinkel killed multiple classmates in a Springfield, Oregon high school. He was later said to have an "urge to kill". This was regarded as evidence of a mental illness, and somehow different from the presumed motives of the several other gun-wielding adolescents who killed their classmates in other schools. These other youths were completely "normal"?

Or as a less extreme example, consider one of my patients with bipolar disorder, a college professor. When she applied for a new drivers’ license, there was the question: "Do you have a mental illness?" What’s she supposed to say, when her symptoms have been 80% controlled for several years, and she has Bipolar II anyway, which has not been recognized as impairing driving safety? The question reflects the expectation: yes, or no? Do you, or do you not? The professor was very uncomfortable with being forced into this black-or-white position.

Mental events of other kinds can also be spread on a spectrum from completely unremarkable ("normal") to very unusual. Fanaticism, for example, demonstrates a continuous spectrum. It extends from people with no particular intense interests; to strongly held beliefs; to extreme beliefs as manifest in some members of Greenpeace or the NRA; to complete loss of perspective as in followers of suicidal religious cults, or Timothy McVeigh (bomber of the U.S. Federal Building in Oklahoma City) ; to overt paranoia such as seems common in the statements of Militant Federalist members (mysterious black helicopters, elaborate conspiracy theories) or the Y2K fearful (no need to stock up on supplies, as the world is coming to an end); and finally to clearly delusional beliefs such as those in the "Unabomber" Manifesto, or Kip Kinkel’s "need to kill".

But a "fanatacism spectrum" makes sane/insane questions much more difficult. Our legal system is predicated upon "black-or-white" distinctions: right/wrong, impulsive/premeditated, sane/insane. Society can handle black and white, but struggles with continuous spectrums.

Yet in the process it leaves patients with bipolar disorder in yes/no dilemmas that have no answer as such. Part of "destigmatizing" mental illness will eventually require recognizing "shades of gray" of mental dysfunction (and their probable genetic basis). We should all resist the question "mentally ill?", as such. It is just another limitation set upon people with mental health symptoms.

Update 6/2005: for another perspective on this issue, which largely supports what you just read but goes far beyond it, demonstrating that bipolar-like symptoms can sometimes be almost more like personality traits, and very positive ones at that -- read John Gartner's book The Hypomanic Edge : The Link Between (A Little) Craziness and (A Lot of) Success in America. Here's a brief comment and link to his book. 

What's the difference between bipolar and "borderline personality disorder"?

If you haven't heard about "borderline", you can skip this section.  For a complete essay on this topic, read here please.  For a discussion on how thinking about "diagnosis" is shifting away from labels like "borderline personality disorder", toward a concept of symptom "spectrum", read this essay on bipolar versus borderline. .  

What’s the latest on what causes bipolar disorder? (updated 9/2007)

Fortunately this story is getting longer quickly!  In other words, our understanding of the causes of bipolar disorder is improving fast.  Unfortunately, despite this improvement, much of which has come in the last two years, the manic side of bipolarity is still very much a mystery. By contrast, the story of bipolar depression appears at this point to be very similar if not identical to the story for Major Depression, the "unipolar" form of depression, which is now becoming much clearer.

Here is a one paragraph summary.  If you would like to see more details, follow the links one paragraph below.  

In brief:  there is clearly a genetic basis for bipolar disorder. Differences in brain function can be seen between people with bipolar disorder and those without it, even when no bipolar symptoms are present at all. In other words, these may be clues to the permanent differences in the brains of those with this illness. What causes mania? In many forms of bipolarity, abnormalities in the "biological clock" appear to be the basis of this strange set of symptoms.  That is probably why changes in the pattern of sleep are so frequently seen at the very beginning of symptom episodes, as our sleep is  very dependent on our internal clock.  The biological basis of depression is better understood.  Many lines of research are converging to suggest that depression is an abnormality in the balance between nerve cell growth and nerve cell shrinkage in specific regions of the brain. Evolution has not eliminated genes associated with bipolarity because they give rise to beneficial traits when they are present in small doses, it is currently hypothesized. 

 

What about hormonal effects on mood? 

When the DSM included premenstrual syndrome ("PMS") as a psychiatric disorder, there were protests in the streets of San Francisco (at the American Psychiatric Association meeting) by women’s groups opposed to making an "illness" out of women’s mood experiences. This point is well taken, and at the same time raises the question again regarding the term "mental illness" (as opposed to "normal"). Meanwhile, growing evidence suggests a need to critically evaluate the role of steroid hormones on mood, as follows.

Research doctors have reported several patients whose anxiety was successfully treated with medications altering steroids.Jacobs, Herzog(a)  DSM "mixed states" and "rapid cycling" are widely recognized as occurring far more often in women than in men.Kilzieh Women with bipolar disorder have a 50% risk of depression after childbirth.Leibenluft Newer antidepressants affect the production of a key progesterone metabolite.Griffin And steroid medications (estrogen and progesterone are steroids too) like prednisone  are recognized as capable of precipitating manic symptoms in both Bipolar I and IIBrown and Suppes.

As I have begun to recognize the importance of these hormonal influences, I have been asking about menstrual function in all women with mood symptoms.  I am astounded at the frequency of abnormalities.  As found recently in a small study on this subjectRasgon,  almost every woman has something amiss.  If cycling, they are irregular; and a surprising number have had uterine or ovarian surgery.  Bad experiences on birth control pills are often common, but dramatic improvements in mood with estrogen have also been seen.  

There is much for us to learn about this. As this is a particular area of interest of mine, in part because it's so obvious and yet we know so little about it, there is now a separate section of this website for keeping track of what's going on in research about Hormones and Mood (at least the research that has direct implications for how psychiatry treats mood problems).  

 

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