COMMENTARY

Bipolar Disorder: Improving Diagnosis and Treatment

Matt A. Goldenberg, DO

Disclosures

June 02, 2015

In This Article

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.[2] 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.[3] 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.

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