NRS 428-Discussion: Unipolar depression

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One of the important developments in the field of mood disorders in recent years in fact is the recognition that many patients once considered to have major depressive disorder actually have a form of bipolar disorder, especially bipolar II disorder or one of the conditions within the bipolar spectrum ( ). Since symptomatic patients with bipolar disorder spend much more of theirFigure 6-21 time in the depressed state rather than in the manic, hypomanic, or mixed state, this means that many depressed patients in the past were incorrectly diagnosed with unipolar major depression, and treated with antidepressant monotherapy instead of being diagnosed as a bipolar spectrum disorder and treated first with lithium, anticonvulsant mood stabilizers, and/or atypical antipsychotics prior to adding an antidepressant, if an antidepressant is even used at all.

Up to half of patients once considered to have a unipolar depression are now considered to have a bipolar spectrum disorder ( ), and although they would not necessarily be good candidatesFigure 6-21 for antidepressant monotherapy, this is often the treatment that they receive when the bipolar nature of their condition is not recognized. Antidepressant treatment of unrecognized bipolar patients

Figure 6-17. . Bipolar III½ (3.5) is bipolar disorder with substance abuse, in which the substanceBipolar III½ abuse is associated with efforts to achieve hypomania. Such patients should be evaluated closely to determine if (hypo)mania has ever occurred in the absence of substance abuse.

may not only increase mood cycling, mixed states, and conversion to hypomania and mania, as mentioned above, but may also contribute to the increase in suicidality in younger patients treated with antidepressants, i.e., children and adults younger than 25. Discussion: Unipolar depression

Thus it becomes important to recognize whether a depressed patient has a bipolar spectrum disorder or a unipolar major depressive disorder. How can this be done? In reality, patients with either unipolar or bipolar depression often have identical current symptoms, so obtaining the profile of current symptomatology is obviously not sufficient for distinguishing unipolar from bipolar depression. The answer may be in part to ask the two questions shown in , namely, “Who’s yourTable 6-2 daddy?” and “Where’s your mama?”

“Who’s your daddy?” can mean “what is your family history?” since a first-degree relative with a bipolar spectrum disorder can give a strong hint that the patient also has a bipolar spectrum disorder rather than unipolar depression. “Where’s your mama?” can mean “I need to get additional history from someone else close to you,” since patients tend to under-report their manic symptoms, and the insight and observations of an outside informant such as a mother or spouse can describe a history quite different from the one the patient is reporting, and thus help establish a bipolar spectrum diagnosis that patients themselves do not perceive, or deny. Some hints, but not sufficient for

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diagnostic certainty, can even come from current symptoms to suggest a bipolar spectrum depression, such as more time sleeping, overeating, comorbid anxiety, motor retardation, mood lability, psychotic symptoms or suicidal thoughts ( ). Hints that the depression may be inFigure 6-22 the bipolar spectrum can also come from the course of the untreated illness prior to the current symptoms, such as early age of onset, high frequency of depressive symptoms, high proportion of time spent ill, and acute abatement or onset of symptoms. Prior response to antidepressants that suggests bipolar depression can be multiple antidepressant failures, rapid recovery, and activating side effects such as

Figure 6-18. . Bipolar IV is seen in individuals with longstanding and stable hyperthymic temperamentBipolar IV into which a major depressive episode intrudes. Individuals with hyperthymic temperament who are treated for depressive episodes may be at increased risk for antidepressant-induced mood cycling, and may instead respond better to mood stabilizers.

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insomnia, agitation, and anxiety. Although none of these features can discriminate bipolar depression from unipolar depression with certainty, the point is to be vigilant to the possibility that what looks like a unipolar depression might actually be a bipolar spectrum depression when investigated more carefully, and when response to treatment is monitored.