Introduction

A previous article, “A Guide to Treating Depression,” discussed the experience of seeing a psychiatrist for the first time. However, not every patient comes to my office for an initial evaluation with depression. Patients often need help with anxiety, obsessive thoughts, psychosis, problems with attention, trouble sleeping, or mood swings. The initial appointment for each of these chief complaints is very similar. As a psychiatrist, I begin by prompting the patient to discuss what brought them in, and what we will be working on together. I then conduct a detailed patient interview history, asking the patient several questions to get me up to speed with regard to their history. In most cases, I will order necessary laboratory tests and collect any relevant collateral information from family and other previous doctors before establishing a diagnosis and treatment plan. My training has taught me to evaluate for specific diagnostic criteria (nuances in the patient’s story) to differentiate between many possible diagnoses. Many of these differential diagnoses present with seemingly similar symptoms to an untrained eye. A proper diagnosis is essential for developing a treatment plan that optimizes outcomes.

In my experience, one of the most difficult and critical diagnostic considerations is differentiating unipolar from bipolar depression in patients who present to the clinic with severe depression. What makes this most challenging is that patients with both bipolar disorder (bipolar depression) and major depressive disorder (unipolar depression) can present with depression that looks, feels, and appears to be identical. Although most patients present to their primary care doctor with depression, the importance of making a correct diagnosis is why I believe that it is good practice to recommend a consultation from a psychiatrist. Psychiatrists are trained to make these distinctions and formulate a proper treatment plan. There is a lot at stake in mistaking bipolar disorder for major depressive disorder; for example, it can lead to worsening symptoms, adverse outcomes, overmedication (or the wrong medication), and unnecessary hospitalization. Therefore, when a patient presents to my office with depression, I always rule out bipolar disorder.

Depression or Bipolar Disorder?

During the initial interview with a patient presenting with depression, I begin by broadly asking the patient, “Have you had mood swings?” If they report they have, I ask, “Please tell me about them.” This allows the patient to report atypical (ie, non-textbook) symptoms that you could otherwise miss if you begin with a very narrow set of questions. I then follow up with a set of more specific, narrowly focused questions designed to steer our conversation to cover the typical symptoms of bipolar disorder and the atypical symptoms of depression that can be a risk factor for bipolar disorder. I am specifically looking for distinct periods of 3-4 days (or longer) when the patient’s mood has been consistently elevated or irritable, and whether during these periods they went without sleep (or had very little need for sleep). Patients with a history consistent with bipolar disorder will usually also report other symptoms during these periods, such as increased energy (despite getting little or no sleep), increased risk-taking behaviors (gambling, spending money they do not have, brief sexual encounters), talking fast, thinking fast, feeling more distracted than normal, feeling on top of the world, and starting a lot of projects. If the patient reports having had these periods of elevated or irritable mood in the past, with several of the associated symptoms, it is likely that they have bipolar disorder (even if they present to the clinic severely depressed). I will address how to screen for the atypical symptoms of depression later, but first we need to complete the process for diagnosing bipolar disorder. There is a final distinction that needs to be made in this regard bipolar disorder: distinguishing between bipolar I and bipolar II.

In my experience, patients with what the most recent version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) calls “bipolar II” will describe that during their mood swings, they are “the employee of the month” or a “social butterfly.” Therefore, during their periods of elevated mood, they often report feeling “great” and look forward to their periods of increased productivity and social confidence. They may report starting lots of projects, having lots of energy, and being very creative during these periods. However, the problem comes later, when their mood crashes. The story many patients report is that these periods of elevated mood are recurrently followed by periods of depression, during which they cannot keep up the pace and maintain their obligations or many of their activities of daily living. In contrast, patients with bipolar I will almost always report that their periods of elevated or irritable mood are very disruptive to their lives. Oftentimes, patients will report getting into trouble in their relationships, with the law, at work, or at home. Patients have reported writing papers or starting projects that they felt “were huge epiphanies or would change the world”; however, later they realized their actions had been “bizarre and did not make sense.” During their periods of elevated mood, some patients report engaging in out-of-character activities that will get them fired or divorced. They report having felt “on top of the world” or “invincible,” only to look back later and realize their behavior was extreme, atypical for them, and hard to explain. I have found patients that with bipolar I report both their mood swings and the crash/depression afterward to be terribly disruptive to their lives and to those around them.

The Tough Cases

Some of the most difficult cases I have seen are those in which patients come to the clinic with depression and deny all of the typical symptoms that would definitively meet the diagnostic criteria for either bipolar I or bipolar II—but for whom something in the personal or their family history suggests that bipolar disorder is possible, or even likely. It is these cases that you will probably find the most difficult to diagnose correctly as well. There is a cluster of suspicious symptoms, often called “atypical depression,” that you can use to improve your diagnostic accuracy. Such factors as younger age at onset of depression (< 20 years), sleeping and eating more during the episode of depression, and onset of the first episode of depression during the postpartum period are all risk factors for bipolar disorder. If patients have a family history of bipolar disorder, a history of not responding well to traditional antidepressants, or a history of multiple episodes of depression (> 6), or if they felt like they lost contact with reality during the episodes of depression (auditory or visual hallucinations), these factors also raise suspicion for bipolar disorder.^[2] Never lose sight of the fact that a patient presenting with depression may have bipolar disorder. Here is a good screening tool to help you make the correct diagnosis. The major reason why it is vitally important to make a proper diagnosis is because the treatments used in major depressive disorder (unipolar depression), bipolar I, and bipolar II are very different. For example, patients with bipolar disorder should not take a traditional antidepressant alone, because it can make their mood swings more frequent and more intense. There are also differences in which medications work best for bipolar I and bipolar II. Traditionally, mood stabilizers and some of the second-generation antipsychotics are the first-line treatments for patients with bipolar disorder, whereas antidepressants (such as selective serotonin reuptake inhibitors [SSRIs]) are the first-line treatment for those with unipolar depression.

In cases where I suspect that a patient may have bipolar disorder, yet I cannot clinically confirm the diagnosis, I often take a step back and do a risk/benefit analysis. In most cases of depression, in my experience, an SSRI carries less risk for adverse effects and is better tolerated than the mood stabilizers and atypical antipsychotics. Therefore, I believe that use of those medications should be reserved for patients who meet the full diagnostic criteria for bipolar disorder or in whom several SSRIs have previously failed. However, as mentioned above, I have found it is best to avoid starting a patient with bipolar disorder on an SSRI, because it can make their mood swings more severe. In patients in whom bipolar disorder cannot be ruled out but depression is suspected, I often discuss the potential risks and benefits of antidepressant therapy—as well as treatment alternatives— and then proceed slowly and cautiously with an antidepressant. In this case more closely spaced follow-up appointments to carefully assess for any appearance of true symptoms of bipolar I or bipolar II are appropriate. If the patient does turn out to have bipolar disorder, I work with him or her to carefully cross-taper to a mood stabilizer. If you discontinue use of the antidepressant too quickly (before the mood stabilizer reaches therapeutic levels), you risk that the patient’s mood will crash and their depression will worsen. Another situation I have commonly run into is that some patients with bipolar II will request to continue their antidepressant vs starting or continuing a mood stabilizer, because they actually prefer their mood swings to be more severe. Many patients are willing to endure severe depression to continue having the periods of elevated mood and the uplifting experiences that can be associated with bipolar II. As mentioned above, they may be the “employee of the month” during these periods, and they are willing to suffer through the inevitable crashes and depression to maintain the occurrence of these “up” periods. However, what I explain to these patients is that the antidepressant is like adding lighter fluid to a fire. They will indeed continue to have periods of elevated mood and like the fire, this will burn brightly for a short time. However, I tell my patients, “Unfortunately, your elevated mood will inevitably burn out; you’ll crash, and you will continue to have periods of severe depression until we get you on the proper medication.”In my experience, the longer a patient with bipolar disorder remains on an antidepressant, the more frequent and severe their mood swings, crashes, and depression will become. Often, I have found that the higher the high periods, the lower the low periods. My goal is to assist patients with bipolar disorder achieve long-term medication management that can take away the peaks (the highs) and the valleys (the depression). This can be especially difficult for patients with bipolar II who enjoy their “up” periods. However, after some time, they adjust to a new baseline and begin to enjoy the security and consistency that comes with a stable mood.

Conclusion

Because the diagnosis, treatment considerations, and ongoing medication management of bipolar disorder can be very delicate and nuanced, I recommend that you refer patients who may have this disorder for a consultation with a psychiatrist. It can be terribly difficult for a patient to seek care for bipolar disorder. I am always pleased to share with them that many of my patients with bipolar disorder are extremely creative and successful. There is no reason why fear of a diagnosis should keep your patient from seeking a consultation with a psychiatrist and from getting the help that he or she needs. Counsel your patients that once their mood is stabilized, they will be able to wake up every morning and count on their mood being solid and no longer a roadblock to their success. If you have a patient, family member, or a friend whom you think needs to get help with their mood, please share this article with them. The more we talk about mental health in the same way that we talk about physical health, the more we can decrease the stigma and shame that often impedes those in our communities from getting the help that they need.

This article first appeared Medscape 2 June 2015.