How to Decide Whether Depressions Are Bipolar Depressions

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BIPOLAR UPDATE

Although the DSM-5-TR diagnostic criteria for a depressive episode are the same for unipolar major depression and bipolar depression, these episodes differ in their natural history (ie, patients with bipolar disorder have mania and/or hypomania), age of onset, suicide risk, associated comorbidities, and biological correlates. Most importantly, they differ dramatically in the effective medications. Thus, it is critical to diagnose these depressions correctly.

To do so, you must take a good history for hypomania or mania. This is where diagnostic errors commonly occur. Start by informing the patient how important it is to have the correct diagnosis for effective treatment and that being wrong about the diagnosis can lead to wrong treatment that, at best, is ineffective and, at worst, very harmful (eg, antidepressants can cause a malignant transformation of bipolar disorder to a rapid cycling and treatment-resistant condition).^1-3 This warning to the patient hopefully undermines possible reluctance to disclose manic symptoms because of the stigma of the diagnosis, because they enjoy the experience, or because they believe that it represents their normal mood and energy that they would like to return to and maintain.

Start by describing an episode of mania or hypomania: how the episodes start, what symptoms occur at the outset, how individuals react when encountering a patient in a fresh mania, how it progresses over the next several days, and how it ends—typically with a crash into depression when they rapidly develop the opposite of all the symptoms they just had.

The patient should first be asked to identify and then focus on periods when they were not significantly using any substances that might produce manic-like symptoms, such as amphetamines, cocaine, and alcohol. Here is how I describe the episodes:

I note that typically, there are no precipitants to the onset of manias. This distinguishes them from the common comorbidity (in the patients I see, veterans) of posttraumatic stress disorder (PTSD), in which agitated, hyperactive states are precipitated when some trigger, interaction, or memory leads to a rush of adrenaline and the “fight or flight” response occurs. This agitation and irritability, which is generally an unpleasant experience, may continue for hours or even part of a day. However, if the patient can get away from the triggering stimulus, the symptoms will subside, and they will return to their baseline state. But with manias, the typical onset is when the patient wakes up, and the experience lasts much longer—at least some of the time. They note racing thoughts with many plans for things they would like to do that day and an unusual amount of energy, motivation, and self-confidence that they can do any and all of these things. They may feel invincible. They want to start new projects and ventures, clean and organize the house, add to their possessions, and contact neglected friends.

The first person they meet, who might be a spouse or family member they are living with, notices that their speech is faster than usual. They may find it hard to understand as manic individuals (without realizing it) may be dropping syllables or whole words because the speech muscles cannot keep up with the speed of the thoughts. The listener will typically respond by asking the person to repeat what they said, urging them to take a breath or slow down, or maybe questioning how much coffee they had that morning. Ask the patient whether they have had feedback like that from listeners at the start of what might be manias.

Next, the individual experiencing mania may tell the person about their plans. And they have a lot to say—they are talking much more than usual, chattier, and even disinhibited in speech, bringing up controversial topics they may regret later. Often, the listener may not agree that these are great plans and may worry that they are unrealistic, impossible, could strain painful medical or orthopedic problems that they have, or maybe the listener may feel there are more important things that the manic person should be doing with this new energy. This could lead to an irritable, if not violent, argument (depending on how insistent the disagreeing person is) because it is usually impossible to dissuade a person experiencing mania from doing what they want to do. They have supreme confidence that it will be easy, and the expenditures will not be a problem (even if they obviously will be a problem).

Next, the person experiencing mania sets out to do those projects in “go-go-go” mode, feeling much less need for sleep and maybe skipping sleep completely for a night or 2. As noted, spending money almost invariably occurs to fund the ventures or add to things they collect; clothes are very common purchases, but there can be big-ticket items like vehicles, expensive lawn equipment, or foolish investments, including scams. The person will later recognize these decisions as foolish, but they seemed like perfect opportunities at the time.

At night, the person experiencing mania wants to continue their projects, but their loved ones may urge them to come to bed, or they may have enough insight to realize they should at least try to sleep. But it is difficult because their brain is still racing with thoughts of plans, making new ones and modifying previous ones. Again, the contrast with what keeps patients with PTSD awake is important—the individual with PTSD has racing thoughts about past and present traumas, current worries, fears of sounds in the house, and disturbed awakenings and nightmares followed by the inability to return to sleep due to these negative thoughts. Patients with comorbid PTSD and bipolar disorder will have some nights when it is the mania keeping them up and others when the PTSD is the cause. Typically, PTSD is the cause of insomnia during bipolar depressions when they have this comorbidity.

After several days or more, the event terminates, usually over a day or less, and there is the crash, as noted before. The victim can feel the energy draining from their body and brain as they lose interest in whatever they were doing and stop working on their projects, leaving them unfinished. They withdraw, do not want to talk to others, and slow down in all respects. Their mood becomes depressed, and suicidality may set in quickly.

Patients experiencing mania may have living spaces littered with tools and supplies for unfinished projects. When the next mania comes along, they usually start entirely different projects and cannot be persuaded to finish the previous ones, which is another source of irritability and conflict with the spouse or family.

Describing mania in this manner takes 5 to 10 minutes. Then, ask the patient whether they have had experiences like this. It counts for the diagnosis if it happened some years ago, but lately, they have been predominantly depressed.

Very often, you will get a strong reaction to the effect that “this is exactly what happens to me; how could you know it so accurately?” They never knew this was mania. Or you may get a reaction that, no, this never happened—and it may be that all the hyperactivity thought to be mania was due to PTSD-triggered events or some other cause related to conflicts with people. The third possibility is that they had some of what you said, but other details were absent. In that case, you flesh out what they claim they did not have in your narrative and see whether it meets the criteria for mania or hypomania.

Once you have determined that they have had manic episodes, the next step is to identify how long the spells last, whether they are rapid cyclers with 4 or more episodes per year (2 manias and 2 depressions would qualify), and whether it is bipolar I or II. This is important because, particularly with bipolar I and with rapid cycling, it is essential to avoid antidepressants. I will discuss treatment in later columns.

Bipolar I is easily diagnosed if they have a history of psychosis with their manias or if they have been hospitalized because of the manias. The more difficult way to meet the criteria for bipolar I is if they have the third criterion in DSM-5-TR, which is “marked impairment in social or occupational functioning” due to behaviors in the manias.

Marked impairment in relationships can come from promiscuity, infidelity to their partner, excessive demands of their partner, or employment of pornography that distresses their partner, all due to the hypersexuality typically associated with manias. I usually wait until now to bring up this symptom. Patients can be ashamed to admit that these things have happened, but by this point in the discussion, they may be ready to discuss it with the clinician. Also, there can be extreme arguments, domestic violence, and intense conflict with significant others, family, and friends about the projects and ideas that the person experiencing mania wants to do. That would also make it bipolar I.

Marked impairment at work typically results from the person experiencing mania being very sure of how things should go at work and wanting to argue with bosses/others to have things done their way. In the process of such arguments, they can be fired, or they may impulsively quit good jobs, thinking that everyone at work is stupid compared with them and that they should seek employment elsewhere, only to regret quitting later when the mania subsides. Patients with bipolar I often have a history of many jobs in a short time due, on close inquiry, to their behavior during their manias.

If the patient does not report criteria-meeting manic or hypomanic episodes, it is still possible that they are having prebipolar depressions and could have a mania in the future.⁴ Initial manias have occurred in older adults after decades of depressions. Predictors of when a unipolar depression diagnosis could change to bipolar include the following: family history of bipolar disorder; a younger age of onset; panic anxiety; a family history of completed suicide; past poor response to antidepressants (even 1 failed trial of an antidepressant should make one pause and wonder whether you missed the diagnosis of bipolar; do not wait until there have been 5 to 10 failed trials); a history of treatment-emergent irritability, agitation, or suicidality after antidepressants; psychotic features; and postpartum depression or psychosis.⁴ If enough of these predictors are present, including failure on previous antidepressant trials, consider treating the depression as a bipolar depression.

Dr Osser is an associate professor of psychiatry at Harvard Medical School in Boston, Massachusetts; a psychiatrist at the Veterans Affairs (VA) Boston Healthcare System, Brockton Division; and codirector of the VA National Bipolar Disorders TeleHealth Program. He reports no conflicts of interest concerning the subject matter of this article.

References

1. Post RM. Preventing the malignant transformation of bipolar disorder. JAMA. 2018;319(12):1197-1198.

2. El-Mallakh RS, Ghaemi SN, Sagduyu K, et al; STEP-BD Investigators. Antidepressant-associated chronic irritable dysphoria (ACID) in STEP-BD patients. J Affect Disord. 2008;111(2-3):372-377.

3. El-Mallakh RS, Vöhringer PA, Ostacher MM, et al. Antidepressants worsen rapid-cycling course in bipolar depression: a STEP-BD randomized clinical trial. J Affect Disord. 2015;184:318-321.

4. Faedda GL, Baldessarini RJ, Marangoni C, et al. An International Society of Bipolar Disorders task force report: precursors and prodromes of bipolar disorder. Bipolar Disord. 2019;21(8):720-740.