More pervasive and disabling than mania.

by John McManamy


ON AVERAGE, we spend far more of our time in depression than we do in mania or hypomania—by a ratio of three to one for those with bipolar I, according to a major 2003 study. Estimates go much higher for those with bipolar II.

This was news to me when I first heard Robert Post, then at the NIMH, give us a preview of his findings at the Fourth International Conference on Bipolar Disorder in Pittsburgh in 2001. The fact that he felt obliged to report this meant it was also news to the 500 or so clinicians and researchers in the room.

At the time, I was into my third year of my bipolar diagnosis. Until then, I had simply assumed that I was some kind of diagnostic oddball—this depressed person who couldn’t be counted on to flip into mania when I was supposed to, a walking black hole, no fun to have around. Why did I always have to be so different?

But now Dr Post was telling me I was normal, at least by bipolar standards. Basically, we are the death of the party, and in this regard I fit right in. Believe it or not, this came as good news to me.

Some people may experience being up more than down, and in rare cases some may never know what it’s like to just want to go to sleep and never wake up. But as a general rule it is much more helpful to regard bipolar as simply another form of depression.

But it’s easy to anticipate resistance to this notion. Why, for instance, should someone whose idea of a wacky wild time out on the town involves coupon night at the Olive Garden be regarded the same as someone splashing naked in a public fountain?



But that is exactly the wrong question to ask. The more relevant query is what do these two individuals have in common? The answer, of course, is their depressions. Our depressions. Because we are down way more than up, we can make a strong case that depression is by far the more disabling, not to mention lethal, part of our illness.

Earth to psychiatry: Our ups don’t define us. Rather, we’re brothers and sisters in depression. If these depressions run a highly recurrent course, then we’re practically identical twins.

Let’s put it this way: If you are depressed, then performing your day job is going to be highly problematic. So is maintaining relationships. So is being at peace (or at least in a state of cease-fire) with yourself. We need our wits about us merely to survive in this world. But—gradually or suddenly—it's as if our brains have quit on us. We can't cope, we can't function.

This is generally the state we're in when we seek out psychiatric help. By contrast, those with mania are generally transported to the emergency room in the back of a police car. Meanwhile, no one ever visited a clinician complaining about feeling wonderful.




Unfortunately, unless a family member is present to inform the doctor about the time you got a speeding ticket while driving from a party with someone else's partner, your doctor is going to assume that you have plain vanilla unipolar depression and prescribe an antidepressant.

In my case, the antidepressant flipped me into mania, which then made the bipolar diagnosis a no-brainer. A good many people, though, may show an initial improvement on an antidepressant before it poops out or agitation sets in or both. The doctor tends to interpret the initial improvement as evidence of a favorable response, and switch to a different antidepressant.

This can go on for years, typically with the patient getting worse rather than better. According to one study, psychiatrists initially misdiagnose half of us. If a primary care physician is conducting the exam, the rate of misdiagnosis shoots up to eight in ten.

According to another study, eight to 10 years elapse from time of first onset to a correct diagnosis. According to two DBSA surveys from 1994 and 2000, one-third of those misdiagnosed remain that way for a decade. Typically, these patients are subjected to endless rounds of antidepressants that are likely to make their condition worse, even much worse, not better.

Major alert: antidepressants and bipolar do not mix.



In a 2013 editorial in the International Journal of Bipolar Disorders, Swiss psychiatrist Jules Angst reported that 40 percent of those treated with unipolar depression are actually "hidden bipolars."

So …

Is there anything in your depression – with no reference to your ups – that might send up bipolar red flags? The most apparent one, it seems, is that those with bipolar depression tend to exhibit vegetative qualities rather than agitated. This includes such features as motor retardation, more time sleeping, and weight gain. In an article in Psychiatric Services in 2001, Charles Bowden of the University of Texas, San Antonio also pointed to acute onset or abatement of symptoms, and greater lability (ie more instability such as mood swings) during episodes.

Dr Bowden’s article represents a consensus among researchers into bipolar depression, so let’s continue. The article also mentioned that those with bipolar depression tend to have much higher scores for extraversion, novelty-seeking, and being less judgmental than their unipolar counterparts.

Dr Bowden also brought up seasonal depression, which is more likely to manifest in those in the bipolar spectrum.

We also have age of onset. As a general rule, bipolar tends to turn up at an earlier age than unipolar depression. Typically, this occurs during the transition from youth to adult, in the late teens and early twenties. But here is the catch: Those first episodes are inevitably depressive ones. The mania outbreaks tend to occur later.

Having pointed out these clues (together with evidence of past depressions), Dr Bowden cautioned that “no single or specific constellation of these symptomatic presentations allows unequivocal diagnosis of unipolar or bipolar depression.”

So there is the rub – no clear-cut picture. Again, we have to be our own experts. Keep in mind, when depressed it is literally impossible to recall when we ever felt good, or even normal, much less feeling manic or hypomanic. If our current depression gives us little to go on, can our past depressions offer up a some clues?

In other articles on this site, I place great emphasis on the fact that bipolar is a cycling illness. In a depressed state, you may not recall your "ups," but you will most likely be able to recollect your downs. Say that time in high school when you went from an A to a C student. Or quit your job or broke off an engagement.

Here, we are seeing indications of past depressions, presumably broken up by periods of "normal."  Recurring depressions, in other words. The strong suggestion here is that your current depression is not your first, that they may have begun at a much younger age, and that it seems that they have cycled in and out over the course of your life.

This, alone, hardly amounts to incontrovertible evidence of bipolar, but we are now on the right track, asking the right questions.

We now have a major red flag that indicates that you could be one of those "hidden bipolars."

Observe everything, take nothing for granted …

Based on my book, NOT JUST UP AND DOWN, June 20, 2016.


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Bipolar Stuff in the Shack with John and Maggie