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)[1] 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.
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Any views expressed above are the author's own and do not necessarily reflect the views of WebMD or Medscape.
Cite this: Matt A. Goldenberg. Bipolar Disorder: Improving Diagnosis and Treatment - Medscape - Jun 02, 2015.
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