HY 01/07: Is It Depression or Bipolar Disorder?

The right diagnosis makes all the difference in getting well

Happy, sad, excited, angry—our moods swing like a pendulum, reflecting the everyday ups and downs in our lives. Most of us take these changing moods in stride. But the pendulum swings are more extreme for the millions of people with mood disorders. “They can be constantly depressed or elated for days or weeks at a time,” says psychiatrist Shanthi Lewis, M.D., of Lehigh Valley Hospital and Health Network.

The two most common mood disorders are depression and bipolar disorder (also called manic-depressive illness). Though the symptoms overlap, they’re separate conditions with different treatments. For people navigating these illnesses, the road to a happier, more productive life begins with the correct diagnosis.

What is depression?
Some 3-4 million men and twice as many women suffer from depression. People with this disorder are overwhelmed by sadness. They feel worthless and hopeless, have a tough time concentrating, and lose interest in life’s pleasures. Their energy level is low, and they may eat or sleep too much or too little. Some depressed people have physical symptoms like headaches or stomachaches. In extreme cases, they are suicidal.

When five or more of these symptoms (including depressed mood) are present fairly constantly for more than two weeks, Lewis says, the diagnosis is definite and severe enough to require treatment. Doctors typically prescribe antidepressant medications and/or some form of talk therapy. The specific combination varies with the individual. Over the long run, knowing what therapies work best can spare depressed people a lot of pain. “Depression is a chronic illness,” Lewis says. “If you had one episode, there is a 50/50 chance you’ll have a second.”

What is bipolar disorder?
Newton’s law of gravity applies to bipolar disorder: When a mood swings up into a mental state called mania, invariably it will swing down into depression, and vice versa. If the mania is mild (hypomania), people with bipolar disorder function pretty well. They’re creative, energetic and goal-oriented—behavior easy to characterize as normal.

Full-blown mania, however, is hard to miss. People in this state can’t focus. They live on very little sleep and engage in risk-taking behaviors like speeding, overspending or hypersexuality. “They think they are invincible,” Lewis says, “which leads to reckless decisions. They’re impulsive and irritable with a low frustration tolerance, and are likely to hurt themselves or others.” Since mania feels good, people with bipolar disorder often resist the treatment they need, or abandon it when they’re not on the depressed end of the pendulum.

Bipolar disorder runs strongly in families. It generally arrives in late adolescence and lasts a lifetime. In between the highs and lows, the patient may seem fine for days, months or even years. But bipolar disorder is a devastating illness that, left untreated, can lead to divorce, job loss, substance abuse and suicide. It’s imperative that patients with this disorder remain under the care of a psychiatrist skilled in its diagnosis and treatment. With proper medication and psychotherapy, experts say, 80-90 percent of patients can be effectively treated.

Why are the two confused?
If you come to your doctor with symptoms of depression, he or she has no way of knowing, on the face of it, whether you have depression or the “down” phase of bipolar disorder. “It’s the mania that distinguishes bipolar,” says family medicine physician Christine Potterjones, M.D., of Lehigh Valley Hospital and Health Network.

It takes only one manic episode to establish a bipolar diagnosis. But if the depression precedes the mania, or the mania is mild enough to fly under the doctor’s radar, people who in fact have bipolar disorder may spend years believing their problem is depression—and getting the wrong treatment. Antidepressants are highly effective against depression. “However, when you give antidepressants to a person with bipolar disorder, you can push them into mania,” Lewis says.

The solution: a careful medical history. Has the person ever had an episode that could be characterized as manic? “Often, family, friends or co-workers can identify the problem better than the patient himself,” Lewis says.

Part of the medical history is looking at the patient’s family tree. “If you have first-degree relatives (parents, siblings) with significant mood disorders, you are at higher risk for developing one,” says Lewis’ colleague, child and adolescent psychiatrist John Paul Gomez, M.D.

The doctor also needs to know about past drug or alcohol abuse, head injuries, hormonal problems, and diseases such as attention deficit/hyperactivity disorder (ADHD), epilepsy or hypothyroidism. Any of these can mimic a mood disorder.

A look into the past may reveal that the patient’s feelings are perfectly normal. People grieving the loss of a loved one, for example, will have the symptoms of depression for a long time. “When something bad happens, such as the death of a family member, we call that an adjustment reaction,” Potterjones says. “This is a case where I can reassure the person that feeling sad and crying a lot is not due to an emotional disorder.”

If the diagnosis does prove to be depression or bipolar disorder, it’s important to make peace with the condition. “We educate patients to accept that their mood disorder is a chronic illness that can relapse,” Lewis says. “To stay well, it’s vital that they comply with treatment.”