Assessment Of Course Of Illness
There is little difficulty for the clinician in assessing early onset and recurrent episodic depression along with seasonality and hormonal status, and changes in the course of illness over time as long as attention is paid to past and prospective course in a methodical manner. This is imperative where there is early onset or a family history of bipolar disorder.
Pictorial graphing representation of the episodes can be particularly helpful and the patient can be engaged in the maintenance phase in depicting this . Unfortunately the use of pictorial graphing of episodes tends to be siloed in the bipolar disorder literature although it is helpful for both unipolar and bipolar illnesses and hence the pictorial representation of course tends to start with a hypo/manic episode and work backward. Staging models of bipolar disorder which identify depression as prodromal or non-specific or at increased risk of bipolar disorder are evolving and not currently yet of clinical help to the clinician’s dilemma .
Depression Attack Vs Episode Of Depression
A depression attack isnt an official or clinically recognized term.
You could, however, experience episodes of depression, or if youve lived with the condition for a while, you could go through periods of time when your existing symptoms intensify.
Depression doesnt typically occur suddenly. But it may be possible that if you live with the condition, a significantly distressing event may intensify your symptoms and make them feel as if they came on out of the blue.
Its also possible for many people to miss the early signs of depression and dont realize what theyre experiencing until symptoms become severe.
Clinical depression, formally known as major depressive disorder, is diagnosed when you experience most of the following symptoms, most of the time, for 2 weeks or longer:
- low mood that can be manifest as sadness, irritability, emptiness, or hopelessness
- feelings of guilt or worthlessness
- recurrent thoughts of death or suicide
- changes in eating patterns which may lead to weight loss or gain
- sleeping too much or too little
- difficulty concentrating or remembering things
- unexplained aches and pains
Only a mental health professional can accurately diagnose depression.
Other Treatments And Suicide
Evidence is growing that the glutamate NMDA-receptor antagonist ketamine and its active S-enantiomer can exert rapid, short-term reduction of suicidal ideation along with rapid reduction of symptoms of depression, including in BD patients, although effects on suicidal behavior are uncertain . There is considerable uncertainty about how to continue use of racemic or S-ketamine following initial benefits, and some concern that its discontinuation may provoke adverse clinical responses . ECT often appears to be lifesaving in suicidal emergencies but lacks evidence of sustained antisuicidal efficacy . Other methods of external electrical or magnetic stimulation of brain, vagal nerve stimulation, and deep brain stimulation are being investigated or introduced for the treatment of otherwise treatment-resistant depression but remain to be tested adequately for specific effects on suicidal behavior, particularly in BD.
Additional interventions of potential value include emergency hospitalization as well as psychotherapies, in particular cognitive-behavioral, dialectic, and interpersonal methods, which can improve depressive symptoms and may reduce suicidal risk . However, results from studies of psychosocial interventions may be limited by the self-selection of patients who adhere to such prolonged treatments.
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Where Do We Stand Today Online Poll Data Focus Groups And Faculty Discussion
To set the stage for this evidence-based exploration of the differential diagnosis of MDD versus BP, 3 online surveys were deployed at Psychiatrist.com, and 2 focus group teleconferences were facilitated by Dr. McIntyre in order to gain an understanding of how clinicians are currently conducting a differential diagnosis. The questions also explored which rating scales were being used, psychiatric and medical comorbidities that may be hindering their efforts, the greatest predictors of an accurate diagnosis, and the risk factors that they believe predispose a patient to BP as opposed to unipolar depression. The online polls received 473 responses, and 20 clinicians participated in the focus groups. The majority of the participants who responded to the surveys as well as those in the focus groups were psychiatrists. This section will provide a summary of highlights from the polls, focus group discussions, and excerpts taken from the roundtable meeting.
Limitations Of The Study
Several limitations should be considered when interpreting the findings of this paper. First, as the study recruited individuals from within bipolar disorder pedigrees, the results may not be generalisable to other populations the major depressive disorder cases included here are not representative of major depressive disorder in general. Despite this, many findings that have previously been reported in the broader clinical literature on bipolar and unipolar depression were replicated in this genetically defined sample, wherein the shared genetic origins would be expected to diminish the likelihood of demonstrating such differences. Second, the sample size, although consistent with many other comparative studies, was not large enough to enable analysis of the bipolar type 1 and type 2 groups separately. The few studies that have separately examined the two types suggest that there may be important differences between them compared with major depressive disorder. Third, this validation of the probabilistic approach was limited, as not all variables included in the original list operational criteria could be included because of the limitations of the version of the DIGS used in this data-set. Finally, the assessment of depressive features was retrospective, as it was premised on the most severe lifetime episode.
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Diagnosing Depression And Bipolar Disorder
If you have bipolar disorder, getting a diagnosis can be complicated because its difficult to recognize hypomania or mania in yourself. If your doctor is unaware you have those symptoms, your illness will appear to be depression, and you wont get the right treatment.
Accurate analysis of your symptoms is the only way to arrive at the correct diagnosis. Your doctor will need a complete medical history. You should also list all the medications and supplements you take. Its important to tell your doctor if youve had a problem with substance abuse.
No specific diagnostic test is available to help your doctor determine if you have bipolar disorder or depression. But your doctor may want to order tests to rule out other conditions that can mimic depression. These tests might include physical and neurological exams, lab tests, or brain imaging.
Treatment will be more effective if you start early and stick to it.
Themes Uncovered By Expert Panel That Could Lead To Diagnostic Missteps
- Ruling out of BP initially by labeling all depressed patients as potentially having BP
- Assumption that TRD is probably misdiagnosed BP without consideration of the many other possible factors that can account for TRD
- Lack of clarity about hallmark symptoms as outlined in DSM-5, which leads to uncertainty in differential diagnosis, due to overlapping symptoms and comorbidity
- Lack of clarity about best predictors of achieving an accurate diagnosis of MDD vs BP and also risk factors that predispose a patient to a bipolar diagnosis
- Overreliance on screening tools to serve as a proxy for diagnosis in lieu of complete clinical assessment and data gathering to fit together the constellation of signs and symptoms
- Discounting of the family history too quickly by inappropriately dismissing it or, conversely, giving it too much weight
- Misinterpretation of the words used by the patient to describe a family members psychiatric history
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Why Call It Unipolar Then
Unipolar depression focuses mostly on the depressed mood state rather than the two-pronged presentation of bipolar depression, which includes the movement between the depressive state as well as the expansive or elevated mood state, explains Lovern Moseley, a licensed psychologist in Boston.
In other words, unipolar means theres one prolonged mood episode in this case, depression. This is in comparison with other mental health conditions, like bipolar disorder, which may lead you to experience changes in your mood, from depression to mania, an elevated mood state.
The Role Of Screening Instruments
The frequency of misdiagnosis and the challenge of differentiating MDD and BP highlight not only the importance of accurate differential diagnosis but also the need for and appropriate use of reliable diagnostic tools. The MDQ is one of several self-administered instruments developed to improve detection of BP.2 It was intended to be used as a screening instrument, not as the diagnostic measure.2 Unfortunately, some clinicians regard a positive screen result in the MDQ as a presumptive diagnosis.6
There has been a desire to get an easy-to-use bipolar screening tool in the hands of busy clinicians that can quickly and easily be almost a proxy for making a formal diagnosis. But screens are just thatscreens they are not proxies for actual diagnoses. Screens are meant to cast a wide net to not miss true cases they are less focused on excluding false positive cases. When we used the MDQ as a structured interview with patients to clarify their self-reported responses, we found very high positive and negative predictive value of a true bipolar diagnosis. The questions within the MDQ provide an excellent basis for a semi-structured interview with the patient that allows an experienced clinician to clarify and contextualize patients responses. Dr Goldberg
Yes, you have to do a clinical interview after you administer the MDQ, or any other screening tool, because of the modest positive predictive value . Dr Zimmerman
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Current Status Of Bipolar Depression
Adequate understanding, timely diagnosis, and effective short- and long-term treatment of depressive episodes in BD patients are critically important but remarkably insufficiently resolved . Clinical significance of bipolar depression is underscored by strong association with overall morbidity, other co-occurring psychiatric conditions , disability, and excess mortality owing largely to suicide in young patients and intercurrent medical illness in older patients .
Bipolar Disorder And Suicide
The depressive phase of bipolar disorder is often very severe, and suicide is a major risk factor. In fact, people suffering from bipolar disorder are more likely to attempt suicide than those suffering from regular depression. Furthermore, their suicide attempts tend to be more lethal.
The risk of suicide is even higher in people with bipolar disorder who have frequent depressive episodes, mixed episodes, a history of alcohol or drug abuse, a family history of suicide, or an early onset of the disease.
Suicide warning signs include:
- Talking about death, self-harm, or suicide.
- Feeling hopeless or helpless.
Get more help
Bipolar Disorder Symptoms, causes, and treatment.
Rapid Cycling Signs, symptoms, and causes of rapid cycling in bipolar disorder.
Bipolar Workbook and other self-help resources.
Hotlines and support
Canada: Visit Finding Help for links to provincial helplines and support groups.
India: Call the Vandrevala Foundation Helpline at 1860 2662 345 or 1800 2333 330
|The HelpGuide team appreciates the support of Diamond Benefactors Jeff and Viktoria Segal.|
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Rates Of Occurrence: Bipolar Vs Depression
Bipolar disorder statistics indicate that approximately 2.8 percent of adults are diagnosed with this condition. Bipolar disorder appears to be equally common in males and females. One study estimated the level of impairment from bipolar disorder ranging from moderate to severe, with the majority of people experiencing serious impairment.
Depression statistics indicate that major depressive disorder is more common than bipolar disorder. It is estimated that approximately 7.1 percent of adults experience a major depressive episode. Unlike bipolar disorder, major depression is more common among females than males, with a prevalence of 8.7 percent and 5.3 percent respectively. The rate of severe impairment is far lower for depression, though a majority of people with this disorder do experience severe impairment.
What Is Bipolar Disorder
Bipolar disorder is a mental health condition that causes extreme shifts in moods that alternate between highs and lows . These manic and depressive periods vary from person to person and can last from just a few hours or days to several weeks or even months. Sometimes these periods of intense emotions are so brief and so far between that many people may not be aware that they have bipolar disorder. Sometimes these cycles are so strong and close together that it is very difficult to maintain a normal life and have normal relationships.
Bipolar depression shares many of the same symptoms of regular depression. Manic episodes are often harder to identify because many people dont understand what the symptoms of mania are. If you experience episodes of depression followed by the following symptoms of mania, you may have bipolar disorder.
- An extremely elated, happy mood or an extremely irritable, angry, unpleasant mood
- Increased physical and mental activity and energy
- Racing thoughts
- Impulsive activity such as spending sprees, sexual indiscretion, and alcohol abuse
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Of The Following Disorders Which Do You Have The Greatest Difficulty Differentiating From Bipolar I Disorder
The poll respondents chose borderline personality disorder as the most difficult to differentiate from BP I, followed by unipolar depression and attention-deficit/hyperactivity disorder . The focus group participants concurred with the poll results and also mentioned substance abuse, undiagnosed traumatic brain injury among combat veterans, and posttraumatic stress disorder as challenges. Mood swings were mentioned frequently during the focus group discussion, and the expert panel made a special effort to stress that mood instability is not among the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition , symptoms of BP but is more of a defining element. It was suggested that clinicians should regard abrupt changes in mood as less likely to be a symptom of BP than of other disorders, such as borderline personality disorder or ADHD.
To set the stage for the focus groups, the following scenario was presented to the focus group to discuss: The patient presents with depressive symptoms. You are not familiar with their personal history and don t know if the patient has ever had a manic episode. What steps do you take to establish your diagnosis for the patient? Common themes from the discussion included the following:
Treatment For Bipolar Disorder
Doctors use mood stabilizers to treat bipolar disorder. Antidepressants can make mania worse. They arent a first-line treatment for bipolar disorder. Your doctor may prescribe them to treat other disorders such as anxiety or PTSD. If you also have anxiety, benzodiazepines may be helpful, but you should use caution if you take them due to their risk for abuse. A variety of new antipsychotic drugs are approved and available for the treatment of bipolar disorder and can be effective. If one of these drugs doesnt work, another one might.
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How To Cope With An Episode Of Depression
Learning to identify what you feel may be the first step toward developing coping skills for what you may think is a depression attack.
Are you experiencing depression symptoms that seem to have come out of nowhere? Or is what youre feeling more similar to anxiety or panic?
If youre not sure, or need support working on self-awareness and managing your symptoms, consider talking with a mental health professional. Besides helping you explore what you feel, they can also recommend a plan that works for your specific case.
If youd like to work on self-care as well, mindfulness is an evidence-based strategy that may help you manage both anxiety and depression symptoms.
Mindfulness and meditation can also help you decrease the chance of panic attacks and intense depression episodes.
Who Experiences Bipolar Disorder
Bipolar disorder usually begins in older teens and young adults, with at least half of all cases appearing before age 25. Children and adolescents, however, can develop this disease in more severe forms and often in combination with attention deficit hyperactivity disorder . Some studies have indicated that bipolar depression is genetically inherited, occurring more commonly within families.
While bipolar disorder occurs equally in women and men, women are more likely to meet criteria for bipolar II disorder. Women with bipolar disorder may switch moods more quickly this is called “rapid cycling.” Varying levels of sex hormones and activity of the thyroid gland in the neck, together with the tendency to be prescribed antidepressants, may contribute to the more rapid cycling seen in women. Women may also experience more periods of depression than men.
An estimated 60 percent of all people with bipolar disorder have drug or alcohol dependence. It has also been shown to occur frequently in people with seasonal depression and certain anxiety disorders, like post-traumatic stress disorder .
Predictive Model Of Bd
The results of a multinomial regression analysis with diagnosis as the dependent variable, using MDD as the reference group, and using symptoms of depression, family history, comorbidities, course of illness, and sociodemographic characteristics as predictors, found that BD-I was significantly associated with restlessness , absence of depressed mood , presence of any anxiety disorder and any personality disorder , earlier age of onset , male sex , being foreign-born , and having lower income whereas BD-II was associated with absence of depressed mood and absence of worthlessness , presence of any personality disorder , earlier age of onset , male sex , and being Black . When all factors were included in the model, the predictive power was 89.93%, standard error = 0.24, , suggesting that the combination of clinical and demographic variables can be helpful in accurately identifying individuals with BD-I and BD-II.