No one complains when they feel really good, and therein lies a problem. The hallmark of bipolar disorder, also called manic depression, is mood swings: periods of deep depression alternating with periods of euphoria. But in some people, the manic phase is extremely mild. They find their euphoria pleasant and don’t seek help, and those around them do not view their elated mood as extreme.
Manic depressives who experience this milder form of mania, known as hypomania, can easily be misdiagnosed, said Hagop S. Akiskal, MD, at the 52nd Annual Meeting of the American Psychiatric Association (APA). If doctors see these patients at all, it is likely to be during a “down” period, he explained.
The result: “Hypomanic” patients are often diagnosed as having major depression and are prescribed the wrong medication when they are in the depressive phase of bipolar disorder. Not only are antidepressants ineffective for treating bipolar disorder–in some patients, they can make the problem worse.
Bipolar I and II: Two Distinct Disorders
Bipolar disorder can affect different people in different ways. For this reason, mental health professionals split manic depression into two types: bipolar I and bipolar II.
In bipolar I disorder, highs and lows are sharply defined. During manic episodes, people are euphoric and may be extremely talkative. They have boundless energy and need little sleep. In full-blown psychotic mania, they can have delusions and hallucinations. During the depressive phase, they exhibit the symptoms of major depression: gloom, lethargy, problems sleeping, self-doubt, hopelessness, and thoughts of suicide.
Bipolar II disorder has been officially classified by the APA as a distinct mental disorder only since 1994. Because their “highs” aren’t manic (hypomania falls between normal elation and mania), bipolar II sufferers appear to have more in common with depressives than with bipolar I sufferers. But research is uncovering important differences between depression and the depressive phase of bipolar II.
Detecting Those with Bipolar II: A Study
Psychiatrists used to think that drugs for classic depression could also be effective in treating the depressive episodes of manic depression. According to Akiskal, this has proven false. Manic depressive illness calls for treatment with a mood stabilizer, not with antidepressants. The mood stabilizer lithium has traditionally been prescribed for many bipolar patients. Antidepressant medication is often combined with lithium, although some antidepressants can trigger a manic episode in some patients.
Despite these risks, said Akiskal, few studies have tried to figure out how the depressive phase of bipolar disorder differs from classic, or unipolar, depression. Two recent studies, however, shed light on some of the characteristics of bipolar II.
A recent French study of 500 patients found that bipolar II patients suffering an episode of severe depression had more thoughts of suicide than did patients with unipolar depression. The majority (88%) of the bipolar II patients had previously always had moderate mood swings, alternating between moderate elation and mild depression. (This is not typical of most patients with classic depression: They may have suffered prior bouts of severe depression, but they do not have what psychiatrists call a “cyclothymic” temperament–that is, a temperament prone to mood swings.)
Another research project, the National Institute of Mental Health (NIMH) collaborative depression study, followed 559 patients with major (classic) depression who had no history of mania or hypomania. Data were collected every 3 months for a decade. The findings: 3.8% of the participants developed bipolar I disorder and 8.6% developed bipolar II disorder.
Those who ended up with bipolar II:
- Had longer, more frequent depressive episodes, and earlier in life.
- Were more likely to be involved in substance abuse.
- Tended to also suffer from anxiety disorders such as obsessive-compulsive tendencies, panic attacks, and anxiety-related physical complaints.
The presence of three traits predicted who would end up with bipolar II: mood swings, depression nonetheless punctuated by “excitement,” and intense daydreaming.
These findings offer clues to doctors that may help them distinguish depression from manic depression. Bipolar II depression seems to be a “more unstable form of depressive illness,” said Akiskal, who collaborated in the NIMH study. An extreme example–though common–is the patient who in the midst of a clinical depression experiences intense sexual excitement. This is called a mixed state.
Such mixed states should send off warning bells among clinicians. Akiskal urged that a family history of bipolar disorder be taken in every patient with depressive disorder. Strong evidence suggests that susceptibility to bipolar disorder is inherited. It is also important to talk to family and friends if bipolar disorder is suspected to determine whether the person displays the mild cycling temperament that is typical of bipolar II patients. After all, as Dr. Akiskal points out, patients themselves aren’t likely to complain about or report the periods in their lives when they felt well. It is important to make the bipolar II diagnosis because the treatment (mood stabilizers) differs from that for major depression (antidepressants). People with both disorders clearly benefit from psychotherapy in addition to pharmacotherapy. Mixed states and potential substance-abuse problems are more important to watch out for in bipolar II patients.
Article By: Carla Cantor, Medical Writer