Diagnosis FAQ

(Updated 12/2014)

There is much more to learn. Here are some of the commonly asked questions. 

What kinds of depression are recognized?

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

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

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 bipolarity.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 is treatment resistant depression?

Substantial controversy exists, even amongst psychiatrists, about the boundaries of this label.  For people who aren’t getting better, it’s simpler to think about treatment options:

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

Recent research has shown that psychotherapy is as effective as medications in many cases (e.g.  mild to moderate depression), possibly with greater long term effectiveness.Frank and Thase

However, after multiple trials of meds and therapy,  there is a group of patients who are truly “treatment resistant” . What then? First,  apply the 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?

Secondly, consider ECT (electroconvulsive therapy).  Though frightening to consider for most people, it still has the highest rate o response in treatment-resistant depression. New advances in technique, like placing both electrodes on one side of the head instead of one on each side (“unilateral ECT” instead of “bilateral), have decreased the memory problems ECT can cause to zero for some patients, but this issue remains a concern.

Somewhere along the way, perhaps after 3 or more antidepressants have been tried, it might be worth considering a mood stabilizer with antidepressant effects (e.g. lamotrigine or lithium) even if there are few signs of “bipolarity”. But don’t forget the psychotherapy approaches: many people keep focusing on medications and overlook a treatment with very low risk and very high potential for benefit.

What if anxiety is also prominent?

Two important principles:

  1. Anxiety can be a bipolar disorder symptom.  That is, it can be part of the bipolar disorder, which will get better as bipolar disorder gets better.ISBD Or it can be a separate condition that will require its own treatment later. But in most cases, when a person has both bipolar disorder and an anxiety disorder as well, many experts recommend  “treat the bipolar disorder first.”
  2. Even though the most common treatment for anxiety disorders is an antidepressant medication, each kind of anxiety disorder has a specific psychotherapy.  In all versions of anxiety except OCD (obsessive-compulsive disorder) therapy works as well as and in some cases better than antidepressants. So if anxiety is still an issue when mood stability is very good (the bipolar component is well-treated), see if you can find a therapist who can offer the psychotherapy specific to your anxiety disorder. This avoids adding an antidepressant, which can make bipolar disorder worse (more anxiety, more manic-like symptoms, more rapid cycling, more treatment-resistant).

Here is much more information on anxiety and bipolar disorders.

Are we stretching the diagnosis too far? 

Even some psychiatrists think this bipolar way of thinking has gone too far. They are concerned that excitement about this diagnosis and the treatment options it opens has become a “bandwagon”. Zimmerman  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 “does this patient 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?”

Lamotrigine, for example, has in 20+ years shown few or perhaps no long term risks.  When it is first started there is a 1/1000 chance of a serious allergic reaction called Stevens-Johnson Syndrome (when the dose is no longer increasing that risk falls back to very near the risk of anyone getting SJS ).  Compare antidepressant risks of sexual problems (nearly 50% if closely queried), weight gain (nearly all of them except bupropion/Wellbutrin),  and recently some question about bone density loss. Moura

So in my view, the emphasis on overdiagnosis risk is leading us away from simpler questions, like “how many antidepressants should a person try before switching strategies?” (like trying lamotrigine, for example,  if psychotherapy has also already been tried in a fair way).

Normal? mentally ill? Where’s the line between them?

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” from above [link to “What is the depression spectrum” in Diagnosis section]:

plain depression------------------------------manic-depressive
("unipolar")                                  (bipolar I)

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); 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. We should all resist the question “mentally ill?”, as such. It is just another limitation set upon people with mental health symptoms.

Childhood bipolar: Does it look different?

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 the 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 avoided until fairly certain, that’s better than missing it entirely, which is the case all too often.

For a reasonably cautious, updated view on this controversial area, see the Balanced Mind Parent Network page on Childhood Bipolar disorders, including a brief summary of the genetic risk.

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 “pathologizing” women’s mood experiences. This point is well taken, and at the same time raises the question again regarding the term “mental illness”. Meanwhile, growing evidence suggests a need to critically evaluate the role of steroid hormones on mood, as follows.

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. And steroid medications are recognized as capable of precipitating manic symptoms in both Bipolar I and IIBrown and Suppes.

Estrogen and progesterone affect mood and anxiety (duh. But did you know that birth control pill users score higher on memory and attention tests? Gogos )  Estrogen increases the action of an “excitatory” neurotransmitter called glutamate, which is so powerful it can damage cells with its excitation effects if not properly balanced. The “yin” to glutamate’s “yang” is GABA, an “inhibitory” neurotransmitter, the activity of which is increased by progesteroneGriffin. Estrogen acts like an antidepressant, and progesterone roughly like Valium or Xanax. But too much estrogen can cause anxiety (just like antidepressants do in bipolar disorder), and too much progesterone relative to estrogen can leave a woman sedated and low-energy. There is a complex balance between these hormones, and that balance varies throughout the menstrual cycle.

Continued research on these hormonal influences will shed more light on the mood variations discussed here as “bipolar disorders”. Perhaps soon we will reclassify some women’s mood variability as a hormonal disturbance, rather than a mood disturbance — but the views of the San Francisco protesters should not be forgotten.  More on Hormones and Mood.

What’s the latest on the cause of bipolar disorder?

This is an area of intense research.  It grew too big for this page. It’s now an entire section of this website.

 

From here, the next page to read might be about Treatment. Or head back to the Table of Contents link above, and work from there.

On to Treatment –>