Why am I still depressed?

McGraw-Hill

Contents

Chapter One

Most mood experts agree that many people have symptoms that represent more than depression, but less than bipolar disorder. But the official rule book of psychiatric diagnosis, the Diagnostic and Statistical Manual of Mental Disorders (DSM) has no place for these folks. So a new system has been growing alongside the DSM approach. Actually, this "new" system is quite old; it just seems new because of how we doctors have been doing diagnosis for the last fifty years. In this emerging way of thinking, diagnoses like depression and bipolar disorder are seen as the ends of a spectrum (as seen in Figure 1.1), and people can be found all along this continuum.

As you can see, at one end is unipolar depression (which the DSM calls Major Depression), and on the other is bipolar (which we're going to examine in more detail shortly). But what, you may ask, happened to manic-depressive? The condition formerly called manic-depressive disorder is the most extreme form of a whole group of mood conditions now referred to as bipolar disorders. This condition is characterized by mania, which can include delusions, hallucinations, paranoia, and all sorts of problem behaviors. Whoa, stop right there! This book is not about mania, OK? It is about the rest of the Mood Spectrum, which by definition does not include mania.

Understanding the Middle of the Mood Spectrum

Because most people think of mania when they hear "bipolar disorder," the idea that a person might have something related to bipolar disorder, even if so mild as to be nearly at the other end of the spectrum, is frightening. You might react to the idea by saying, "Me? Hey, I know what manic means, and I know I've never had that." But you may not know about all the other bipolar versions in the middle of the Mood Spectrum. You may only know about the most extreme form of bipolar disorder and not the subtle variations that can look much more like plain depression.

Wow, that's a lot of terms already: unipolar, major depression, bipolar, manic, and bipolar variations. Does it matter that much what you call it? Oh, definitely, and here's why. Antidepressant medications can make bipolar disorder worse. They can cause people to have a manic episode, including not only the positive, or euphoric, version where you feel "on top of the world," very confident, and full of potential, but also the negative, or dysphoric, version where you feel agitated and angry, and believe that the people around you are stupid, slow, and pathetic.

Negative version of mania? This may be a new idea for you, but it is not a new idea for psychiatrists, who have long recognized that mania is not always a euphoric experience. Although most people associate the idea of mania with feeling good (much too good, in fact), another version of mania is harsh and unpleasant. This version shares the acceleration of the euphoric version, with very rapid thinking, rapid action, and intense, powerful passions. But there is nothing euphoric about it; in fact, it is quite the opposite and thus the term dysphoric. Anger and worry are often very prominent.

Unknown to many people, the negative version is at least as common as the euphoric version. Even less known to most people is that the negative version of mania can occur at the same time as depression symptoms, as you'll see in Chapter 2. This mixed state is known to carry a high risk of suicide. Most mood experts believe that antidepressants given to someone who has bipolar disorder can cause dysphoric mania and mixed states. This phenomenon is one reason why the U.S. Food and Drug Administration (FDA) recommended that everyone given an antidepressant should be screened for bipolar disorder. As you may have heard, the FDA evaluated reports of people who committed suicide shortly after starting an antidepressant. The FDA concluded that at least some of this risk comes from people who look like they have Major Depression (unipolar), but actually have bipolar disorder and receive antidepressants only to end up in an agitated mixed state. The sidebar presents an example of this state, induced by an antidepressant.

The DSM Versus the Mood Spectrum

To understand the importance of a spectrum way of thinking about psychiatric diagnosis, it is important to understand the current, somewhat opposite system of the DSM. The spectrum system sees conditions on a continuum, as in Figure 1.1. The DSM sees conditions as defined by the presence or absence of specific findings. Consider, for example, the DSM criteria for Major Depression, which, believe it or not, I've simplified here:

A. At least one of the following three abnormal moods significantly interfered with the person's life:

1. Abnormal depressed mood

2. Abnormal loss of all interests and pleasure

3. Abnormal irritable mood if person is eighteen or younger

B. At least five of the following symptoms have been present during the same two-week depressed period:

1. Abnormal depressed mood

2. Abnormal loss of all interest and pleasure

3. Appetite or weight disturbance, either:

* Abnormal weight loss (when not dieting) or decrease in appetite

* Abnormal weight gain or increase in appetite

4. Sleep disturbance, either abnormal insomnia or abnormal hypersomnia

5. Activity disturbance, either abnormal agitation or abnormal slowing

6. Abnormal fatigue or loss of energy

7. Abnormal self-reproach or inappropriate guilt

8. Abnormal poor concentration or indecisiveness

9. Abnormal morbid thoughts of death (not just fear of dying) or suicide

C. The symptoms are not due to a mood-in congruent psychosis.

D. There has never been a Manic Episode, a Mixed Episode, or a Hypomanic Episode.

E. The symptoms are not due to physical illness, alcohol, medication, or street drugs.

F. The symptoms are not due to normal bereavement.

As you can see, the DSM criteria are not particularly user-friendly. They look oddly precise and yet arbitrary. For example, according to the DSM criteria for bipolar disorder, a manic episode must last at least seven days. Well, what should be done if some-one's manic episode lasts six and a half days? Is this not bipolar?

However, the DSM actually does serve several useful purposes. For one thing, it is an important tool in research settings. Doctors in Pittsburgh, Pennsylvania, can study Major Depression and compare their results with doctors studying Major Depression in Dallas, Texas, and assume that they are studying roughly the same thing. Clinicians like me (who see patients most of the day, most days a week, as opposed to a researcher, who generally sees a lot fewer patients per week) can read their published research and apply the results to a similar set of patients in their own practice.

In addition, the DSM categories, such as Major Depression and Bipolar Disorder, can be used as a common language by all who understand its diagnostic rules. This enables doctors and therapists to converse easily using a common set of assumptions about broad diagnostic categories.

Because the DSM has value in these ways, we should not ridicule it or throw it out. We just have to recognize its limitations, and recognize that the spectrum model described in this book has some advantages as a way of seeing.

There is a term for this way of thinking about models, such as the DSM versus the Mood Spectrum, called heuristics. In plain English, it means something like this: Make an educated guess, and see how it works. Try a certain way of thinking or looking at a problem. If using that guess or model seems to lead to better outcomes, keep using it. If not, try another. The next section explains how the Mood Spectrum concept is a useful tool in just this way.

The Mood Spectrum: Just a Different Way of Thinking

In the DSM mode of thinking, making an accurate diagnosis requires determining whether the patient with depression symptoms is unipolar or bipolar, whereas in the Mood Spectrum approach, we clinicians don't ask what might be the most accurate label for you. Instead, we ask where might your symptoms lie on the Mood Spectrum. The Bipolar Clinic at Harvard's teaching hospital recently began using a system like this, which they call the Bipolarity Index. Instead of saying "yes" or "no" as to whether you might have a bipolar disorder, they try to determine how much bipolarity you have. (More about the Bipolarity Index appears in Chapter 3.) But just in case you're starting to feel lost in all the lingo and ways of thinking, remember this. Your diagnosis has two main functions:

1. To help guide you to effective treatment

2. To offer some clues about your future (such as, Will this go away? How bad could it get? Will it come again? or Might my children get it?)

Some people can find themselves in the middle of a debate between doctors about what they have, where neither diagnostic function is occurring. Unfortunately, as you may have experienced, this unipolar-or-bipolar debate can become quite intense. When doctors disagree, the patient can be stuck in the middle, which is never good. If that happens, everyone needs to relax and remember that diagnoses are merely best estimates of reality, not reality itself. Diagnoses are heuristic: they are supposed to help us, not make the process more difficult! Ten years from now, I hope the understanding of mood disorders will have improved so much that our present views will be an embarrassment: "Look how confused we were!"

Using the Mood Spectrum to Diagnose Bipolar Variations

In Figure 1.1, you saw arrows indicating people evenly distributed all the way along a Mood Spectrum. But is this really so? Are there really people at all points along this continuum, or are there natural gaps separating one diagnostic group from another? This very idea was studied by Dr. Franco Benazzi, a mood researcher in Italy who found no such gaps. While this is just a single study, his work suggests that no natural cutoff can be found when trying to distinguish unipolar disorder from bipolar disorder. So there must be a "mixing zone" in the middle where bipolar symptoms have diminished, and finally a point at which they diminish to zero. Thus with a Mood Spectrum way of looking at things, one can have "a little bipolarity." While this might strike you as strange, it's what this very chapter is about—so read on.

Yes, you can have "a little bipolarity," so little that you might not have even wondered if you had manic depression or bipolar disorder. But here's why you should wonder: perhaps you have enough bipolarity that antidepressants carry more risk for you than in people who are more unipolar than you. Perhaps you have enough bipolarity that you might do better with the treatment approaches used for people who are more obviously bipolar than you.

Naming and Understanding the Different Types of Bipolar Disorder

As you continue to learn about the Mood Spectrum in this book and from other sources, such as the Internet, you will encounter different labels for bipolar variations. There are two current labels for "a little bipolarity." Chapter 2 looks at one way, called hypo-mania, especially subtle hypomania. Chapter 3 looks at another way that has been called soft bipolar disorder and also examines how bipolar blends into normal. Finally, we'll get to the making of your diagnosis in Chapter 4. However, first let's take moment to get these names straight. The official bipolar subtypes are often depicted with a diagram such as Figure 1.2. The boxes below the line depict depression, and the ones above the line depict hypo-manic or manic symptoms. The severity of symptoms is shown by the height of the box.

Bipolar I (Mania)

Bipolar I (Mania) is the combination of full manic symptoms (detailed in Chapter 2) as well as full depressive symptoms. When the manic episodes are primarily euphoric, this is often called classic bipolar disorder. This version was formerly known as manic-depressive disorder; though euphoric mania is what most people think of when they hear the word bipolar. But, as you are learning in this book, the reality of bipolar disorder is vastly more diverse and complex.

Bipolar II (Hypomania)

Although the term hypomania was informally used for many years, it wasn't until the 1994 edition of the DSM that it became an official term. If you recognize the Greek prefix hypo as meaning "under or less than," you can figure out that hypomania means "a little mania." That's pretty close: manic symptoms, but less severe and sometimes shorter.

By definition, Bipolar II includes the most common set of symptoms found on the spectrum, namely the combination of hypomania and full depressive symptoms. The term Bipolar II is often used to refer to the entire spectrum between Bipolar I and unipolar. However, as you'll read in Chapter 2, hypomania has many variations. Granted, this chapter shows that people can indeed be "a little bipolar" by having just a little hypomania. But having severe hypomania is not little. It may be as bad as or worse than having mania itself. The suicide rate in Bipolar II is as high as, and in some studies higher than, in Bipolar I. Watching patients go through the agitation that comes with severe hypomania, one can understand this research finding.

The trick is to remember that manic episodes can be a very negative experience. Roughly half the time that people are manic, the experience is not euphoric, or full of great confidence, joy, hope, and pleasure, but dysphoric, where people experience most sensory input as harsh and unpleasant (lights are too bright, noises are too loud); their thoughts are rapid, intense, and often extremely negative and angry; and they find other people to be too slow, stupid, and irritating. This is also true in hypomania. Many clinicians think that patients like their hypomania and will conceal it, or even fail to recognize it as abnormal. This may be somewhat true for subtle forms of hypomania, but much less so for severe hypomania. People do indeed recognize their agitation, insomnia, and acceleration. When they find something that makes it stop, they are generally very inclined to stick with that solution (managing alcohol or avoiding late night light, as discussed in Chapter 11, or using mood stabilizers, which are discussed in Chapter 8), unless the solution comes with significant problems of its own. Fortunately, clinicians now have many treatment options and can often find one that does not place the patient in this dilemma of choosing between symptoms and side effects.

Cyclothymia

Even though Cyclothymia is also an official term in the DSM, this diagnosis is rarely used. Because it is characterized by mild depression, in distinction to the full depressions associated with Bipolar II, there may be a natural avoidance of this term by both patients and doctors alike who may hesitate to label such mild symptoms, particularly with a bipolar name.

Bipolar NOS (Not Otherwise Specified)

The DSM uses the NOS label for conditions that don't meet the criteria of the official labels. Thus there are also Depression NOS, Anxiety NOS, Psychosis NOS, and so forth. Bipolar NOS is supposed to describe patients who have some bipolar features, but do not qualify for a particular bipolar variant recognized by the DSM. In practice the NOS label sometimes may be used so the practitioner doesn't have to be more specific about exactly which kind of bipolar disorder is involved. In addition, because the very name is rather vague, some doctors—and perhaps patients—think less stigma might be associated with this particular label. Although clinicians are not supposed to do this, I know they sometimes even use Depression NOS for patients with bipolar features that might otherwise be coded Bipolar II, hoping that Depression NOS is the least stigmatizing of all these labels.

(Continues...)

Excerpted from Why am I still depressed?by Jim Phelps Copyright © 2006 by James R. Phelps, M.D.. Excerpted by permission of McGraw-Hill. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
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