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It is the manic phase of bipolar disorder that attracts—no, demands—attention. But those who have the illness, or love someone who does, know it is depression that most disrupts and devastates lives—and dominates the course of the illness.By Donna Jackel “Few people understand [that] depression sucks the life out of you,” says C.A., 52, of Oregon. “Desires, self-esteem, motivation, self-worth—any of those qualities that keep you going in life—disappear.” Since her 2002 bipolar diagnosis, she has gone only 18 consecutive months without depression. When P.S. of Halifax, Nova Scotia, is sad, she sometimes avoids bike riding with her seven-year-old daughter. The guilt she feels at withdrawing from her child only intensifies her depression. “You look at the functional outcomes, such as the ability to work, family life, being an active participant in society—this is largely driven by depressive, rather than manic, symptoms,” notes Roger S. McIntyre, MD, associate professor of psychiatry and pharmacology at the University of Toronto, and head of the Mood Disorders Psychopharmacology Unit at the University Health Network in Toronto. One reason depression is more debilitating than mania is that it lasts longer; another is that it occurs more frequently: According to a 2002 study by Lewis L. Judd and colleagues at the University of California at San Diego published in the Archives of General Psychiatry, people with bipolar I experience depression three times as often as mania. For bipolar II, the ratio of time spent in depression versus mania is a whopping 40:1. Bipolar depression is also difficult to diagnose, and therefore to treat. Some studies suggest that as many as 50 percent of those with bipolar disorder are misdiagnosed with unipolar depression, according to Michael E. Thase, MD, professor of psychiatry at the University of Pennsylvania School of Medicine and author of several books on bipolar, depression and related topics. It’s not surprising that misdiagnoses frequently occur. The Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV), doesn’t distinguish between bipolar and unipolar depression. Rather, a bipolar diagnosis is made based upon whether the person has experienced mania or hypomania. People with bipolar I experience depression three times as often as mania. “Bipolar depression looks very similar to major depression, with no distinct features,” says McIntyre. “That being said, people with bipolar depression more often complain of symptoms that are atypical for unipolar depression, including increased eating, sleeping, and profound reduction in energy. Moreover, people with bipolar depression also frequently complain of seasonal worsening and ‘therapeutic misadventures’ with antidepressants—that is, the depression gets worse with antidepressant therapy.” Because bipolar and unipolar depression can “look” so similar, psychiatrists must take care to get detailed family histories—and to ask patients if they have ever experienced symptoms of mania or hypomania, says Eric D. Caine, MD, chairman of psychiatry at the University of Rochester Medical Center and an international expert on suicide prevention. Otherwise, “the tendency is to treat it as if it’s unipolar depression, with antidepressants alone, which may serve as rocket fuel for a manic episode,” he adds. HOW IT FEELSHow does one experience bipolar depression? That depends upon whom you ask. Many people undergo distinct periods of stability, mania, and depression. Yet other individuals can feel both depressed and manic at the same time—simultaneously feeling very sad and energized. Holly A. Swartz, MD, associate professor of psychiatry at the University of Pittsburgh School of Medicine, says it is relatively rare for people to meet the DSM-IV criteria for a mixed state, which requires a major depressive episode and a manic episode nearly every day for at least one week. “However, individuals meeting diagnostic criteria for either a depressive episode or a manic episode often have a few subsyndromal symptoms of the opposite pole of the disorder that co-occur with their predominant mood episode,” Swartz says. “For example, someone will meet full criteria for a depressive episode but will also have racing thoughts.” Rapid-cycling—as defined by the DSM-IV diagnostic criteria—is having at least four distinct episodes of major depression, mania or hypomania, or mixed symptoms within a 12-month period. But it is possible to experience more than one rapid-cycling episode a week, or “even within one day,” according to the National Institute of Mental Health. Just because you are feeling down when you wake up and hypomanic later in the day, however, doesn’t mean you are rapid-cycling, emphasizes Joseph R. Calabrese, MD, director of the Mood Disorders Program at Case Western Reserve University in Cleveland. He says consumers often confuse mood lability [instability] with rapid-cycling. Only about 15 to 20 percent of people with bipolar experience rapid-cycling, he adds. Jennell A., 53, of The Villages, Florida, says her moods shift quickly—sometimes from one hour to the next. “Yesterday morning, I woke up at 5:30 a.m. and by 8:00, I knew I was in a hyper-manic cycle,” she says. I was running around nonstop, never stopped talking, and felt like I was running a marathon all day.” But the next morning, Jennell, who awoke early for a golf date, felt like she was “in a fog.” “I knew I could either get up and get going, or spiral into the depressed side of me. I went golfing!” TRIGGERSAs with mania, knowing what stressors leave you vulnerable to depression can help prevent recurrences. Lack of sleep, work-related stress, and traumatic events can all be triggers. For T.L.’s husband, holidays are particularly difficult—they stir unhappy childhood memories. Vacations are also potential land mines. “After a couple days, he becomes extremely irritable and annoying,” says T.L., who lives in Wayne, New Jersey. “He can’t relax, which is no vacation for either of us! It seems to have to do with breaking out of his work routine and structure. Even on weekends, he tends to be more symptomatic.” Then there are the stress factors beyond one’s control—such as ill health or the death of a loved one. “The economy has greatly affected our finances and our work situations,” says Therese J. Borchard, a mother of two, popular blogger (Beyond Blue on beliefnet.com), and author of several books, including the memoir, Beyond Blue: Surviving Depression & Anxiety and Making the Most of Bad Genes (Hachette Book Group, 2009). “It has taken about nine months to navigate through that stress, but now that we have found a way to produce enough income, I think I will be less prone to fall into depression.” KEEPING THINGS STEADYThe severity of the illness, one’s support system, the luck—or failure—of finding effective medication, a competent doctor, and a supportive partner—all affect how successfully bipolar depression can be stabilized. Muriel H. of Easley, South Carolina, managed to teach for 32 years, in part because of her husband’s steady encouragement, but some days it took all her inner resources to make it through the day. “Had it not been for my work ethic, I would have been home in bed,” Muriel says. “On many weekends, I would hole up in my apartment, not coming out again until Monday morning.” Severe bipolar depression not only robs one of the ability to enjoy life, but also may even interfere with basic acts of self-care. C.A. lives directly across the street from a grocery store, but recalls one morning when even that short distance was too far to walk. She showered, applied some makeup, but found she couldn’t leave the house. “I stood at my bedroom window, looking across the way at the store and crying. I felt helpless and stupid.” It is when we are in absolute despair that we most need the comfort of loved ones. The irony is this is also the time when we feel the most unlovable, are least able to return love, and tend to strain the devotion and patience of even the most steadfast caregiver. T.L. knows her husband’s depressed when he grows quiet, turns from sweet to “snappy,” has trouble sleeping, becomes overly critical, and begins obsessing over trivial things, like irritating TV commercials. As soon as she observes such symptoms, T.L. asks her husband how he’s feeling and whether anything is stressing him out. “One time, I was on the computer and he came down to the office to say good night. I was in the middle of writing an email. He gave a big sigh, stomped up the stairs, and slammed the bedroom door. I went up and calmly asked what his problem was, and he snapped something about not kissing him goodnight … as if I could read his mind. I quickly realized this was an [irrational] conversation, told him so and to get some sleep, and we could have a rational conversation the next day, which we did.” THE DARKNESS OF DESPAIRWhen the darkness doesn’t lift, despite the help of family and modern medicine, many people lose all hope. According to the National Mental Health Association, 30 to 70 percent of suicide victims suffered from major depression or bipolar disorder. And a 2000 study conducted by researchers at Johns Hopkins University found that approximately 25 to 50 percent of patients with bipolar attempt suicide at least once. The light in the seemingly endless darkness of depression is that people do recover and rebuild their lives. A mixed state can place a patient at particularly high risk of suicide, says Caine of the University of Rochester. “In a mixed state, someone has the thinking and motor features that are much more like someone on the manic end of things,” he says. “But you can also be very suicidal then. It’s a time of impulsivity and very rapid actions. It may appear like the suicidality is sudden, but the person may have been thinking about it for a long time, and now they have the fuel to do it.” The trick for doctors and caregivers is not to be fooled by body language—someone in a mixed state can be smiling and standing straighter, yet still be capable of suicide. SELF-HELPHaving a plan in place can help prevent minor symptoms from turning into a full-blown episode, says psychologist Elizabeth Saenger, PhD, an assistant professor at Columbia University’s department of psychiatry. She suggests: “Work with a mental health professional to put together a plan: ‘How will I recognize when I am beginning to get depressed? How will my family?’” Saenger also recommends enlisting a trusted friend or family member who isn’t afraid to tell you, “I think you should go to the doctor.” And then do it. Jennell has a rich support system—a caring husband who will play cards with her for hours to distract her from her depression, a therapist she sees every other week, and a psychiatrist she visits monthly. She also has her faith. “God plays an important part in my life in everything I do,” Jennell says. “Having that as my main support gets me by.” P.S. of Halifax says her psychiatrist is the “one constant” in her life. “I really rely on her. I respect her opinion. If she tells me to back off—that I’ve taken on too many projects—I might argue some, but eventually I realize she’s right.” The light in what can—at times—seem like the endless darkness of depression, is that people do recover, find medications that work, and rebuild their lives. Two years ago, Borchard would have said that her depression “got in the way of everything.” Not anymore. “Today I can honestly say that my illness has made me a better spouse, mother, and worker because I’ve had to learn how to use an incredible amount of discipline with just about everything: from sleeping to eating to exercising and communication, to workload and relationships,” Borchard says. “I take every step of life with much more deliberation and care. If I get lazy, it could literally cost me my life because my illness needs healthy relationships and healthy life habits.” Sidebar: Depression Symptoms MAJOR DEPRESSIVE DISORDERFeelings of hopelessness, pessimismFeelings of guilt, worthlessness, helplessnessDifficulty concentratingLoss of interest or pleasure in hobbies and activities that were once enjoyedDifficulty sleepingOvereating or loss of appetitePersistent aches or pains, headaches, cramps or digestive problems that do not ease even with treatmentThoughts of suicide, suicide attemptsBIPOLAR DISORDERFeelings of hopelessness, pessimismFeelings of guilt, worthlessness, helplessnessDifficulty concentratingLoss of interest or pleasure in hobbies and activities that were once enjoyedMay experience sleep disturbances, or oversleepingOvereating or loss of appetitePersistent aches or pains, headaches, cramps, or digestive problems that do not ease even with treatmentMore suicide attempts than with major depressive disorderA profound loss of energySevere depression more likely to include psychotic symptomsOnset of depression occurs at a younger ageMore likely to have a co-occurring mental illness, such as obsessive-compulsive disorder, panic disorder, or substance abuseMore likely to have a family history of maniaMore episodes of depression than with unipolar depressionUse of antidepressant—without mood-stabilizer—may cause hypomania or mania About the author: Donna JackelSource:Donna Jackel is a health writer based in Upstate New York whose work has been featured in Gannett Newspapers and The Bark, Rochester and Her magazines. http://www.bphope.com/
hello without giving an excess of background story, i've been diagnosed with "depression" for a while. the last time it got really bad was a few months ago when i was in russia, when i barely ate, had really bad insomnia (sometimes not sleeping at all) and began to feel as though i was already dead or a ghost or had begun to be out of phase with the rest of the world somehow (although i don't think these were delusions - just sort of "feelings"). i would think of suicide a lot and come close to attempting a few times. anyway i went to the doctor in russia and they prescribed me trazodone and phenzepam (sleeping tablet) which seemed to make my mood swing worse between suicidality and sort of frantic agitation (i bought 3 coats out shopping once even though i didn't really need any of them) and eventually i decided to go back to the UK where i actually live. that day that i decided to do that i suddenly felt my mood swing up again and i went out by myself, drank and took some of my tablets recreationally and was generally very excitable and euphoric. when i got back it was 2am but i wasn't tired despite hardly sleeping the night before and having had lots of CNS depressants and was thinking about going out again, but my room mate got annoyed and i got annoyed with her and so i woke up everyone in the hotel we were in by banging on all the doors and shouting. then i started to pack my stuff and booked a flight for the next day. someone unfortunately called the russian paramedics and they decided to tranquilise me. anyway long story short i was back in the UK. still sort of suicidal and depressed and irritable and slightly on the paranoid side ("everyone wants me to die" etc... but again, i would say this expressing a sort of feeling, i don't think it was a delusion because i would be vaguely aware of the silliness of the idea. sort of.) but things worked out over the next few weeks apart from a few blips (one of those blips being a botched suicide attempt but still). now the last three weeks. OKAY. a week ago, after a two-week depression, i woke up thursday morning having gone to bed at about 2 at about 6.30 am. very unlike me. the days before had been the worst for the depression so far, staying in bed all day, sleeping to avoid crying, suicidal thoughts etc. but i woke up in the morning and after a few mins of grogginess, the fog sort of cleared and i felt very awake. i felt more energized than usual, more excitable, just BETTER. i went out to do stuff, to find stuff to do. i searched out people to speak to. i sat with my friend and some of his friends i'd never met before. they found me a bit odd, as i would cycle between hyper, irritated and depressed every 10 or so minutes. laughing excessively at my own jokes, going off on little rant tangents about people who'd wronged me, picking discussions with people, accusing random people of discussing me. etc etc. but at any rate, i felt increasingly that irritability and rage began to define my mood at the time. in the end i called my ex, who refuses to speak to me anymore since january because of my verbal anger outbursts (:(), i was really agitated and upset because i'd seen he was planning a birthday party. so i asked if i could go. he said "er no". but i didn't have any verbal outbursts i was quite controlled imo. anyway the phone call ended and i was even more agitated and confused and angry, pacing around the room planning to go to his house or his friend's house just because i needed something to do with myself. so i called my other friend and he convinced me to go to the hospital instead. at the hospital after a looooong wait they gave me a sleeping tablet and told me to come back the next day. they irritated me too. i noticed, as i'm sure they did, that i was very talkative. you don't realise how talkative you actually are and how much you feel the need to talk until someone is there having a conversation with you. so i went back the next day. i woke up at 8.30 having gone to bed at about 1 or something. better. i felt still somewhat sedated from the zopiclone when i got to the hospital. sort of quietly sad. the psychiatrist i saw wanted me to try sertraline. this made me feel annoyed for some reason. i don't like SSRIs, although i've taken citalopram before. i felt no one had provided me with a satisfactory explanation as to why i should take an SSRI. anyway i decided to make a big scene about it. so a manager came and spoke to me and i argued with him and was hostile etc (who wouldn't be at some random who'd just said i need therapy and i have a personality disorder as a weapon to get me to be meek??????) anyway then i waited for a consultant. i began to feel more euphoric again rather than irritable. i was still overtalkative when i met the consultant. he said i was hypomanic and gave me quetiapine. this is when it gets a bit more complicated because what is the quetiapine and what is the POSSIBLE hypomania? i was told to take 300mg the first night and 600mg after. 300mg knocked me out for 12 hours a night and made me basically useless, i couldn't do anything. so i decided to just take 300mg rather than 600 as i feared that would be even worse. in the evenings i could feel the effects wearing off and i'd feel MUCH better - i don't know if it was normal better or hypomanic better though! i have no idea anymore :( after two nights of this i decided that too was intolerable, so on monday evening i decided i wouldn't take it. i stayed up until 2 as usual and woke up 4 or 5 hours later, feeling driven and euphoric, getting lots of stuff done in one day. that night again i decided not to take it, slept for 4 hours again. during this time i made only one or two reckless purchases - i bought a couple of tickets for nights out, one of which is tonight, assuming i would go to them when i most likely wouldn't have. i also bought a bag to hold my vinyl (and the vinyl itself i think i bought at this time). i decided to get into glitch, techno and breakbeat and spent a lot of time downloading (this didn't cost me anything though....). i also tried to get into contact with a few men i hadn't spoken to. however while my mind would rush through the day, and even when i went to sleep it felt like i wasn't sleeping because songs and thoughts would whizz through my head, it was like i was awake the whole time still, my body still felt it. when i woke up the second day i could sort of feel that my body was tired but my mind wasn't, my eyes would sting a bit but i'd go on anyway. and sometimes any muscle aches would disappear with a new burst of a pervading sense of euphoria. a couple of other things i would associate with this time - the eyes of anyone looking into the camera in advertisement posters etc would take on an uncanny sort of significance, direct orders (like for traffic) would as well. not a direct, concrete significance, i would just feel a certain "uncanny" feeling. also i would eat fast. it's odd because as i don't have any work or a job or anything i tend to feel i lack things to do, but now i would always have something to do. anyway that afternoon i felt i'd "come down" a bit so to speak, and i went back home, my body feeling heavier, and had a nap for an hour or two, although still with the sense that id been sort of awake the whole time. i thought i was back to normal but again i could feel the irritability and sense of purpose rising when my mother rang me about something (which on the other hand could be perfectly normal!) i decided to take the medicine. it knocked me out again, but the next day the euphoria seemed to break through it, so that i felt sort of sedated and muted but also i cleaned my room, did the laundry, cooked etc, completed with a sense of wellbeing and pleasant gorgeousness. that evening i prepared to go out, but i felt rather down, oddly, for the first time. i decided to take 600mg as i was supposed to. NEVER DOING THAT AGAIN. i slept for 16 hours and was useless for another 2. no euphoria but i think that was over anyway. what makes me think that i wasn't hypomanic - the sense that my body still felt it missed the sleep even if my mind wouldn't switch off, i didn't have any TOTALLY unrealistic plans or make HUGE dents in my bank account. i'm not sure what to do. i can't tolerate the quetiapine it's absolutely awful. what do i do? because the quetiapine sort of interfered when i was in the middle of it, does that change the nature of things? did it cause the stuff that happened on tuesday and wednesday? because overall you might say i had thurs+fri+mon(evening)+tues+wed = 5 days of hypomania = "hypomanic episode". but, like, really? REALLY?! i find this difficult to believe. i found it more difficult to believe before tbh but i guess with the thing that happened in russia etc... it's hard to know what would be "me" and what would be "illness". also REALLY/!?!?!?!?!