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Bipolar Depression

Bipolar Depression

Imagine for a second the psychiatric profession personified as Homer Simpson, with the trademark gesture of the hand smacking the forehead. The collective “Doh!” you hear is the seemingly overnight realization that depression rather than mania is the dominant partner in manic-depressive illness (bipolar disorder). As Michael Thase MD of the University of Pittsburgh observed at the 2002 American Psychiatric Association annual meeting: “Although manic episodes are often more the emergent and notorious phase of bipolar affective disorder, depressive episodes last longer, are typically harder to treat, and result in the high ultimate risk of suicide.”

A 2003 GlaxoSmithKline-funded study carried out by Robert Hirschfeld MD of the University of Texas in Galveston found that those with bipolar disorder fared significantly worse in their depressions than those with unipolar depression. According to the study, individuals with bipolar depression “were more likely to report that they did their work poorly, felt ashamed of their work, had arguments outside the home, felt upset, and never found their work interesting compared to those with unipolar depression. The bipolar depression group also reported significantly more disruption in work, social and family functioning, and significantly more symptom days versus those with unipolar depression.”

According to a Stanley Foundation Bipolar Network survey of 258 of its bipolar patients, this population was depressed three times more than they were manic, despite being treated with an average of 4.1 medications. A 2002 NIMH study found that bipolar I patients were depressed 32 percent of weeks over a 12.8 year period as opposed to being manic or hypomanic for nine percent of weeks and mixed or cycling for six percent of weeks. For bipolar II patients, the same study found depression present in 50 percent of weeks over 13.4 years as opposed to one percent of weeks for mania or hypomania and 12 percent of weeks for mixed or cycling.

The same set of studies also found that dysthymia (minor depression) and subsyndromal (not full-blown) depression dominated, with bipolar II patients more likely to have major depression and a more chronic course. Meanwhile, early data from STEP-BD’s first 500 patients has found 80 percent of relapses were into depression.

For bipolar II, Hagop Akiskal MD of the University of California, San Diego found this population spent an incredible 37 days for every one day hypomanic.

Notwithstanding these sad facts of life, Robert Post MD, head of the Stanley Foundation Bipolar Network, pointed out in a paper at the 2001 APA annual meeting that ” has received relatively little systemic study.”

The DSM-IV fails to distinguish between unipolar and bipolar depression, though there may be subtle but critical differences. Alan Swann MD of the University of Texas, Houston at the 2000 APA annual meeting observed that those with bipolar depression are more likely to manifest psychomotor retardation and have atypical features (such as excessive eating and sleeping) than patients with unipolar depression. According to Dr Swann, bipolar depressions are characterized by greater episode frequency, earlier onset, greater co-occurring substance abuse, and a more equal gender ratio.

Philip Mitchell MD of the University of New South Wales at the 2003 Fifth International Conference on Bipolar Disorders cited a 2000 Australian study of 83 bipolar depressed and 904 unipolar depressed patients that found bipolar patients were more likely to be melancholic (69 vs 37 percent), and were significantly more likely to demonstrate psychomotor disturbance and guilt. A 2001 study by Dr Mitchell of 270 depressed patients found those with bipolar were less tearful than those with unipolar depression, but felt more worthless, exhibited greater loss of pleasure, and experienced more subjective restlessness, leaden paralysis, and hypersomnia than their unipolar counterparts.

Significantly, in the words of Dr Swann, “the differing biological properties of unipolar and bipolar depression suggest that treatments that were originally intended for unipolar depression may not be optimal for bipolar depression.”

These distinctions tend to be lost on the average clinician. A survey by the Depression and Bipolar Support Alliance of 400 of its members found that of those who reported having bipolar disorder, 60 percent disclosed that their initial diagnosis was major depression.

From a patient’s perspective, the implications are enormous. According to a study by S Nassir Ghaemi MD of Harvard et al appearing in the October 2000 Journal of Clinical Psychiatry, it took bipolar I patients nearly six years and bipolar II patients 11.6 years from first contact with the mental health system to achieve a correct diagnosis.

Enter Homer Simpson. Close-up to the hand smacking the forehead a second time. The look on his face says it all. How could I have been so stupid? Bipolar depression. Even the experts can miss the obvious.

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