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Bipolar Disorder: When Depression Isn't Just Depression

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Riley, a fictitious patient, was first depressed in high school. "I remember not caring about anything. I didn't see my friends. I just wanted to sleep. I seriously considered suicide. I had always been a worrywart, but my anxiety was out of control". She never sought treatment, assuming she was over-reacting and no one could help.

When she was 21, Riley experienced a period of four or five days when she didn't seem to need sleep and had high energy and seemingly endless optimism. "I never felt so good. I felt smart and sexy and creative". She emptied her bank account buying things she didn't want or need. Her usual anxiety disappeared and she had abundant confidence. One night she slept with two men she didn't know, which was completely out of character. She used cocaine. She argued bitterly with her friends and family, who she felt were trying to stifle her fun and creativity.

Those few high days were followed by depression, which prompted her to see her family doctor. She didn't mention her uncharacteristic behavior because she felt ashamed. She was prescribed an antidepressant but it made her feel worse, as did another one she tried, so she gave up. She remained unhappy and anxious with rare highs. "I just thought this was me, like being unhappy was my personality". Now 25, Riley is three months' post-partum and depressed.

Many of you will see yourself in Riley's story. Unfortunately, I hear of similar experiences every day, from people who have spent decades suffering from depression that never got better. They recall short periods of feeling great in their 20s and 30s, but the majority of time they felt depressed and anxious. Treatment either helped quickly and just as quickly stopped working or made them feel much worse.

Riley has bipolar disorder (BD), a mental illness usually characterized by episodes of high and low moods. There are three types: BP type one (BPI), type two (BPII) and "soft" BP. Riley best fits the diagnosis of BPII because she has episodes of depression and hypomania.

Hypomania is a high or euphoric mood that lasts four or more days associated with uncharacteristically risky behavior (e.g. promiscuity, excessive spending, drug use), high energy, less need for sleep, and irritability.

Mania includes the same symptoms as hypomania but is far more severe. Manic patients are at imminent risk of harm and usually require hospitalization. Mania may also include psychotic symptoms, most often grandiose delusions, which are false beliefs of greatness (e.g. "I was chosen by God to save the world").

Many patients with hypomania know their behavior is excessive or unusual, but manic patients lose insight and do not believe their behavior is dangerous or that their beliefs are false.

Just one manic episode is required for the diagnosis of BPI, although most patients also experience depressive episodes. The diagnosis of BPII requires hypomanic and depressive episodes. Nearly everyone with BP has significant anxiety symptoms, including worry about daily life (health, finances, family), social anxiety and/or panic attacks.

Feeling smart, sexy and full of optimism doesn't usually provoke a doctor's visit, so GPs often see BP patients only during depressive episodes. Major depressive disorder (MDD) and BP depression (BPD) are often indistinguishable. Patients sometimes don't remember ever feeling high when they're depressed, they may be embarrassed to admit their hypomanic behavior or they're not asked about hypomania. This may lead to years of misdiagnosis and inappropriate, ineffective treatment.

BPD does not respond to antidepressants like MDD. Patients sometimes experience a rapid response to antidepressants that quickly poops out or antidepressants make them feel far worse, mentally and physically. Sometimes antidepressants can provoke mania or hypomania. Antidepressants can be helpful for BPD and anxiety, but should only be used if absolutely necessary and in concert with another medication that helps to stabilize mood.

Although mania is more severe than hypomania, BPII patients spend more time ill (usually depressed) and are at greater risk of suicide. It's hard to stay on treatment because mania and hypomania feel good, but medications prevent ups and downs, which protects the brain from illness progression. When you spend most of your life depressed, those high times feel incredible. Patients miss the highs and when they're well or high, they sometimes forget how terrible depression feels.

There are some features of BPD that may help to differentiate it from MDD. The first episode of BPD usually occurs before age 25, while the onset of MDD is often in the late 20s or 30s. In the early years, BP patients often describe a "rapid on/off pattern" and multiple episodes of depression. BPD is more often associated with food cravings or binge eating and an excessive need for sleep, instead of insomnia and loss of appetite.

Patients may feel heavy or weighted down, like their limbs are full of lead. They might feel better for short periods, often hours, when something enjoyable happens, but quickly descend back into despair. They can be extremely sensitive and over-react to negative social interactions. Depression with psychotic symptoms or post-partum depression may be suggestive of BP.

The most important risk factor for BP is a family history. However, the diagnosis might never have been made so it's important to look for a family history suggestive of BP. A family history of chronic depression and anxiety, institutionalization, "nervous breakdowns", suicide, alcoholism and substance abuse or family chaos might suggest BP.

After years of an unstable mood, BPII patients often become chronically depressed and rarely, if ever, experience hypomania. Worse, they report cognitive symptoms like poor memory and cognition and feel emotionally flat or unable to feel. Once the disorder is chronic, treatment is often less effective. If you read about Riley and see yourself, talk to your doctor. Read more from reputable websites, like mood disorders associations or Most importantly, speak up and ask for help. If you don't receive it, ask again. Don't give up.