Bipolar Depression: The Great Masquerader

t is Tuesday, around 2:30pm. As I look through my afternoon schedule, I am suddenly struck with a feeling of despair. Eva is scheduled for an appointment. I am unsure of the cause of this feeling.

Perhaps it’s from fear, frustration, or inadequacy on my part because I know full well that Eva would be coming in again having done poorly on yet another antidepressant. I can only imagine how frustrated and hopeless she must feel having struggled with depression the better half of her life. Eva is once again at a cross road in her life. A clear-cut sense of urgency surrounds her as she is close to being divorced for a second time and facing further isolation from her children. She has also recently lost yet another job. I fear that Eva is close to the end.

Retrospectively, Eva seemed to do very well until her early 20s, when she suffered her second bout of depression following her first pregnancy. She had a previous episode while in high school but basically ignored it as it left as quickly as it had come. Since then, it seems as if she has gone in and out of depression over the past 12 years, never really “feeling well” for any length of time, despite having tried several antidepressant medications under her physicians’ supervision. This is quite a contrast from the young lady who was always on the go, full of energy, and living life to the fullest. Eva’s first marriage unfortunately ended as her spouse could no longer take her volatility and abuse. Her sexual indiscretions were the final blow. Eva was an enigma to her family, her friends, and her physicians.

At first glance, when looking at any particular snapshot in time of her depressive episodes, Eva appears to present as a typical case of someone suffering from episodes of unipolar depression, and possibly depression with a comorbid anxiety disorder. However, looking at Eva’s longitudinal life course from her adolescent years forward presents a very different case. Unfortunately, looking at the facts of her case, it appears that Eva, like 69% of other patients who suffer with bipolar depression, has been misdiagnosed. Many patients often suffer for years before an accurate diagnosis is made. These patients are commonly diagnosed as either unipolar depressed or as suffering from depression with comorbid anxiety disorder. Today, although bipolar depression is more commonly recognized, it still remains an elusive and difficult diagnosis for many. As it currently stands, the DSM-IV criteria are relatively insensitive, making diagnosis a challenge not only for primary care physicians, but for psychiatrists as well. Once commonly conceived of and recognized only in its extreme forms, bipolar disorder represents a vast spectrum of severity ranging from requiring hospitalization, to much “softer” manifestations of escalating anxiety or irritability combined with or alternating with depression. This bipolar disorder spectrum has a lifetime prevalence of approximately 7%. Undoubtedly, as diagnostic criteria become more sensitive, the prevalence of this disorder may rise. Because this “softer” disease state is relatively common, it will most frequently be encountered in the primary care office.

Reluctance by patients, unwillingness of physicians to diagnose and “label” patients as bipolar, as well as difficulty with diagnostic criteria, are only the tip of the iceberg when dealing with this disease state. Unfortunately, bipolar depression carries a significant stigma, not only in society in general, but from an insurance and healthcare standpoint as well. Although the spectrum disorders represent a “softer” form of disease state, the label of bipolar carries significant social weight.

Although primary care physicians may see patients with bipolar spectrum symptoms on a daily basis, they may have significant concerns about treating those patients. Perhaps if these patients were assigned a pseudonymous diagnosis of “Cyclical Mood Disorder,” might physicians be more willing to treat them? Perhaps with revision of diagnostic criteria, revision of nomenclature may well be in order for the sake of this devastating illness. Sadly, lack of understanding of medical co-morbidities, lack of understanding of mood stabilizing agents, and a fear of legal ramifications can be significant barriers that deny these patients access to proper care.

I think it is a mistake to think of bipolar depression as a physical disease state. In actuality, it is a metastatic disease not only of the psyche of the afflicted person, but a metastatic disease of family, friends, and society in general. The magnitude of the socioeconomic and interpersonal burdens imposed on patients and caregivers by this disorder can be extreme. In 1998, the average direct medical care costs per patient ranged from $ 11,720 with a single episode of mania to $ 624,785 for patients with non-responsive or chronic episodes. Furthermore, the indirect costs in 1991 amounted to $38 billion dollars. Bipolar disorder itself carries significantly higher rates of medical co-morbidity when comparisons are made to the general population at large.

Comparatively higher rates of cardiovascular, pulmonary, and gastrointestinal illness are seen in patients diagnosed with bipolar depression. High rates of interpersonal impairments in areas of daily life, work, school, interpersonal relationships and social functioning add to the already significant burden carried by those afflicted, with the ultimate potential devastating consequence of suicide, with the highest rate of lifetime risk falling into the bipolar II patients. Lack of recognition, mistreatment, submaximal treatment, and unwillingness to treat can have profound effects on the quality of life of patients with bipolar depression. The likelihood of achieving significant treatment response and improving patients’ well-being is reduced in each of these scenarios. On the forefront of science today, the neurobiological data is impressive. It is suggestive that bipolar depression may lead to a neurodegenerative process and that aggressive, early intervention may provide neuroprotective benefits. Bipolar depression is a significant illness, not only for those afflicted but also for society in general. Aggressive education surrounding early recognition and treatment are paramount for patients.