30 March 2018 is World Bipolar Disorder Awareness Day
Bipolar depression is a difficult but important diagnosis which is sometimes missed and often made late by GPs and psychiatrists. It describes major depressive episodes when they are accompanied by hypomanic episodes (bipolar type I disorder) or recurrent depressive episodes (bipolar type II disorder).
The dramatic symptoms of hypomanic episodes are difficult to miss and include rapid thoughts, talking very rapidly or excessively, inflated self-esteem and reckless behaviours. However, the more subtle displays of the less severe hypomanic symptoms can be deceptive. Although hypomanic symptoms are essentially the same as manic episodes, there are reduced in intensity, but the mood change can be severe enough to affect others.
Patients with bipolar disorder often do not recognise and identify hypomanic symptoms themselves, considering them to be part of their normal state, and therefore they often fail to report them. The diagnostic challenge can be even greater if mood disorders occur with another condition including anxiety, substance misuse and personality disorder.
Often people with bipolar depression also have higher rates of psychiatric illness within the family and a family history of bipolar disorder. They also feature the following:
• onset of illness before age 25
• a high number of recurrent episodes
• abrupt onset and end of depressive episodes
• suboptimal response to standard anti-depressants
• episodes of high mood induced by standard anti-depressants
• disruption of social and occupational functioning
• higher rates of substance misuse
Diagnosis is often delayed by several years and frequently patients will have had alternative diagnoses before the correct diagnosis of bipolar depression is made. Making the diagnosis correctly is important as it should lead to a specific and effective treatment.
Standard anti-depressants alone are not the preferred treatment for bipolar disorder and can be associated with problems, tending to destabilise some patients while providing only a partial treatment response.
The treatment of choice would be medications identified as mood stabilising medication. In particular, Quetiapine at a lower dose is licensed for treating bipolar depression, and an effective alternative is Lamotrigine, particularly for women. Lithium is still the gold standard and Depakote (Sodium Valproate), is particularly helpful for male patients. Occasionally mood stabilisers will be accompanied by a low dose of an anti-depressant. Getting the correct diagnosis can be a huge relief to patients and can help them to manage their disorder over time, sometimes in combination with other psychotherapy treatments such as Cognitive Behavioural Therapy or by keeping regular mood charts. With the correct diagnosis and a combination of treatments, patients with bipolar disorder can go on to live normal and happy lives.
Consultant Psychiatrists Dr Winbow and Prof Hale have many years’ experience in diagnosing and treating patients with bipolar disorder. To make an appointment with either consultant, please contact us.