Sharon asks…

If you are a bipolar who has never had a manic episode but experiences only depression, how is that different from plain old depression? How does a doctor or clinician make the diagnosis? I ask because I started on Prozac in 1993 and had a phenomenal positive reaction, which lasted a number of years until it finally wore off. I tried, with a psychiatrist, many different anti-depressants (though not tricyclics) and nothing worked, until finally he gave me Lamictal (lamotrigine) and Prozac (fluoxetine). This has worked very very well for me for about a year (knock on wood), but I never considered myself bipolar, only depressed. Just curious if there’s any neurological difference anyone knows of.

Dr. Fink answers…

Hi, Sharon. The short answer is that based on the situation you describe, I wouldn’t consider you bipolar, either. Now, if you said you had experienced a hypomanic or manic episode in the past, that would likely change the diagnosis.

The diagnosis of bipolar disorder cannot be made without at least one episode of mania or hypomania present at some point in the person’s life. People who have recurrent episodes of depression would be described as having recurrent unipolar depression.

The diagnosis of mania is usually straightforward, but hypomania is a bit fuzzier. In addition, periods of higher energy and productivity may be called hypomania or they may simply be seen as periods of not being depressed. So that can be a fuzzy diagnostic area.

Lamictal is well known to have antidepressant properties. It is used frequently in people with recurrent unipolar depression and people whose depression is or has become resistant to antidepressants alone. A depression that remits in response to Lamictal does not imply a diagnosis of bipolar disorder. Similarly lithium is used to treat treatment resistant depression – as a booster agent for antidepressants that aren’t providing enough relief alone. We do not diagnose bipolar disorder just because lithium was a good medicine for someone’s depression.

I wish we had more neurologic evidence in our database to help understand depression and bipolar disorder – so far the research is early and unclear. When we have those pieces of the puzzle, many of these kinds of questions can be answered much more readily – although it is likely to still be a complicated story because of the complexity of brains and the illnesses that affect them.

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Sharon’s question also is an important reminder of the challenge of diagnosing bipolar in a patient who really has bipolar but never experienced the manic side of the illness. Doctors should try to screen patients for bipolar who only report experiencing depression. The screening usually consists of questions about possible manic or hypomanic episodes in the patient’s past. Doctors may also look at the patient’s family history to assess the likelihood of the patient having bipolar disorder.

This screening is important to determine the safest possible approach to prescribing medication. If the doctor believes that a bipolar diagnosis is possible, the doctor may want to first try the patient on a mood stabilizer that has antidepressant properties, such as lithium or Lamictal. These medications have antidepressant effects with little or no risk of triggering mania; in fact, they typically reduce the likelihood of a manic episode occurring. If the depression continues, the doctor can then prescribe an antidepressant more safely with the mood stabilizer helping to protect against a manic switch.

Unfortunately, such screening is not always effective. Doctors may not ask the right questions, patients may not recall or report episodes of hypomania, and families are not always forthcoming about their medical histories.

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TherapistFinder.com (February 25, 2010)

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PsychCentral (February 25, 2010)

TherapistFinder.com (February 25, 2010)

    Last reviewed: 25 Feb 2010