A bipolar depression is a depressive episode occurring in context of bipolar disorder. When diagnosing depression, it is imperative to first exclude an underlying bipolar disorder. This is because the medication treatment for bipolar depression differs from that for “unipolar” depression. People with bipolar disorder have manic or hypomanic episodes. These are periods of persistently elevated or irritable mood along with feelings of grandiosity, decreased need for sleep, talkativeness, racing thoughts, increase in sexual drive, increased goal-directed activity, or excessive involvement in risky or impulsive activities.
Individuals with bipolar disorder spend around 40% of the symptomatic time being depressed (Judd et al., 2002). Moreover, people with bipolar disorder are more likely to seek help when they are depressed. Therefore, it is not uncommon for bipolar depression to be misdiagnosed as unipolar depression or major depressive disorder. The consequences of such a misdiagnosis may result in treatment with antidepressants, some of which can cause mood episodes to occur more frequently in people with bipolar disorder (Hirschfeld, 2014). Pointers that suggest a possibility of bipolar disorder are as below (Goodwin & Jamison, 2007; Hirschfeld, 2014):
- Family history of bipolar disorder.
- Earlier onset of depression (early 20’s).
- Multiple past episodes and psychiatric hospitalizations.
- Seasonal mood episodes.
- Switching into mania or hypomania on antidepressants.
- Depressive episodes characterized by increased sleep, increased appetite, and weight gain.
- Depressive episodes mixed with hypomanic or manic symptoms.
- Depressive episodes with psychotic symptoms such as delusions or hallucinations.
If you have been diagnosed with depression and notice one or more of the above features, complete the Mood Disorder Questionnaire (MDQ), which is available on the Depression and Bipolar Support Alliance website (http://www.dbsalliance.orgMDQ can correctly identify almost 75% of people with bipolar disorder and also correctly screen out 90% of people who don’t have bipolar disorder (Hirschfeld et al., 2000). Consult your mental health or primary care provider for a more comprehensive assessment if you screen positive for bipolar disorder on the MDQ.
Depression with mixed features: Sometimes people with depression may experience some manic/hypomanic symptoms, but never a clinical manic or hypomanic episode. In such cases, the most likely diagnosis is major depressive disorder with mixed features (American Psychiatric Association, 2013). Recognizing mixed symptoms in context of depression is important as they are a risk factor for future bipolar disorder and make depression less responsive to antidepressants (Hu et al., 2014).
To learn more about self-management techniques for depression, please refer to the evidence-based bestseller The Complete Guide to Self-Management of Depression: Practical and Proven Methods. This comprehensive and easy-to-read book offers the reader a menu of options to self-manage depression that go above and beyond the traditional approaches to treat depression and includes complementary and alternative medicine approaches, exercise, mindfulness, role of social support, and bright light therapy. Besides therapy techniques, the book also provides an evidence-based overview of the role medications in treating depression - when to take them, how long to take them, when and how to stop them, and what to do when medications stop working.
HARPREET S. DUGGAL, MD, FAPA
American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association.
Goodwin, F. K., & Jamison, K. R. (2007). Manic-depressive illness: Bipolar disorders and recurrent depression (2nd ed.). New York, NY: Oxford University Press.
Hirschfeld, R. M., Williams, J. B., Spitzer, R. L., Calabrese, J. R., Flynn, L., Keck, P. E., Jr., Lewis, L., McElroy, S. L., Post, R. M., Rapport, D. J., Russell, J. M., Sachs, G. S., & Zajecka, J. (2000). Development and validation of a screening instrument for bipolar spectrum disorder: the mood disorder questionnaire. American Journal of Psychiatry, 157(11), 1873-1875.
Hirschfeld, R. M. (2014). Differential diagnosis of bipolar disorder and major depressive disorder. Journal of Affective Disorders, 169(S1), S12-S16.
Hu, J., Mansur, R., & McIntyre, R. S. (2014). Mixed specifiers for bipolar mania and depression: highlights of DSM-5 changes and implications for diagnosis and treatment in primary care. Primary Care Companion for CNS Disorders, 16(2), pii: PCC.13r01599. doi: 10.4088/PCC.13r01599. Epub 2014 Apr 17.
Judd, L. L., Akiskal, H. S., Schettler, P. J., Endicott, J., Maser, J., Solomon, D. A., Leon, A. C., Rice, J. A., & Keller, M. B. (2002). The long-term natural history of the weekly symptomatic status of bipolar I disorder. Archives of General Psychiatry, 59(6), 530-537.