Joe,
“As you are aware, the DSM-5 criteria for a major depressive episode are the same for unipolar and bipolar disorders. I am currently working with a severely depressed client, should I also be assessing and evaluating him for a possible bipolar disorder also”?
Sally, LCSW
Sally’s recent e-mail to me poses an interesting dynamic: Since the presenting symptomology in such a client is often overwhelmingly depressive in nature, it can be a challenge for us clinicians to lean toward bipolarity as a possible differential. Nevertheless, we should, because unipolar depressive episodes do indeed differ from bipolar depressive episodes in their natural history (patients with bipolar disorders will have distinct episodes of mania or hypomania) age of onset, suicide risk, and other co-occurring disorders. And quite important, these episodes differ markedly in the medication management approaches employed pursuant to optimal treatment. (Traditional antidepressants are the priority pharmacological treatments in unipolar major depression but are ineffective and possibly harmful in bipolar disorder as they can trigger affective switching and/or rapid cycling).
Due diligence thus means conducting a thorough history for mania or hypomania – because this is precisely where diagnosis can go off the rails. Why? Because mania is often perceived by bipolar patients as a highly desirable state until it ends, chaos ensues because of their erratically energetic activity, and they descend into the dramatically uncomfortable throes of a switch to a depressive episode, which serves as the catalyst to seek help.
Investigating Mania
Mania can be uncomfortable to talk about for patients, and in my experience, some don’t have a clear impression of what it actually is and how it presents to others. As such, I’ll begin my investigation with some innocuous questions such as “what diagnosis have other clinicians discussed with you”? If they respond they’ve been previously diagnosed with bipolar, I’ll ask why – to determine what circumstances lead the treating clinician to conclude that bipolar is the issue. Some clients will respond they were hospitalized or incurred dire consequences resulting from manic episodes, so I will pursue how long these episodes typically last, how frequently the associated behaviors occur, and whether they cause significant impairment socially, professionally, financially, or legally. This will help to narrow down whether the patient meets criteria for bipolar I or II, as well as rapid versus nonrapid cycling.
If the client had not previously received a bipolar diagnosis and is unclear about what I’m asking, I’ll pose this question: “Have there been times in your life when you’ve felt like the Energizer bunny, having considerable energy for getting things done, with little need for sleep, and feeling really up such that other people noticed and commented that they thought you were acting oddly or different”? If the client confirms manic-like symptoms proceed as above, and do more digging for additional details.
If the patient doesn’t report symptoms meeting criteria for manic or hypomanic episodes, it’s still possible they might have a “prebipolar” depression presaging a future manic or hypomanic episode. A number of factors may serve as predictors as to when a unipolar major depressive diagnosis could morph into a bipolar diagnosis. If enough predictors are substantiated (significant family history, younger age of onset, family history of completed suicide, psychotic features, previous poor response to antidepressants), it is best moving forward to treat the depression as bipolar, while tapering off any traditional antidepressants in favor of mood stabilizers or second general antipsychotics approved for bipolar depression management.
Attribution Statement:
Joe Wegmann is a licensed pharmacist & clinical social worker has presented psychopharmacology seminars to over 10,000 healthcare professionals in 46 states, and maintains an active psychotherapy practice specializing in the treatment of depression and anxiety. He is the author of Psychopharmacology: Straight Talk on Mental Health Medications, published by PESI, Inc.
To learn more about Joe’s programs, visit the Programs section of this website or contribute a question for Joe to answer in a future article: joe@thepharmatherapist.com.