The Depression-Mania Two-Step

John McManamy Health Guide
  • Last week, the American Psychiatric Association’s DSM-5 Task Force released the draft to the new DSM, available for viewing and comment on the APA website. The new version of the DSM is scheduled for publication in 2013. Two days later, I presented my initial take in a sharepost here at BipolarConnect.

    I am also doing a running series of blog posts in my daily blog, Knowledge is Necessity. More recently, I issued a three-part Report Card concerning the DSM’s take on major depression. This involved a detailed breakdown of nine critically important diagnostic issues that have a direct impact on our well-being.

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    Today, I issued Part One to my Bipolar Report Card, which covered six topics. I anticipate at least three more installments. (Links to specific pieces are posted at the end to this sharepost.)

    What I would like to do here and in future shareposts is comment on some observations that jumped out and hit me in the face as I was “grading papers,” and in turn invite your feedback. So, let’s begin ...

    What came through very loud and clear is how intimately depression is bound to mania/hypomania. We can’t just pretend that the two occupy poles at opposite extremes with a huge gap in the middle. If I had my way, I would scrap the term bipolar entirely and replace it with something like “cycling disease.”

    Think of depression and mania as dancing to the same music, but maybe with no mania for a good many individuals, just a subtle invisible force tugging from the other end. Two years ago, at a psychiatric conference, I heard Gary Sachs MD refer to depression as the pointer stars in the Big Dipper that showed the way to the North Star of mania/hypomania.

    Why would you use depression to draw a bead on mania? Simple. We don’t seek out psychiatrists when we are feeling good. Typically, we are depressed, and when we are depressed we totally lack the ability to recall when we felt good, never mind feeling entirely too good for our own good.

    This happened to me. My psychiatrist carefully listened to my tale of woe, then misdiagnosed me with unipolar depression. The antidepressant he prescribed flipped me into orbit. Once I was on a mood stabilizer and was able to think straight I was able to determine that my psychiatrist wasn’t to blame for making the wrong call.

    Trust me, there was no way in the shape I was in that he was about to mistake me for the type who danced on tables.

    My position began to shift when I researched my illness and discovered a depression is not just a depression, that there are very clear as well as subtle differences in the way unipolar and bipolar depressions present.

    I’m sure the doctor must have asked me if I had ever experienced depression before and that  I would have responded yes. Way back in junior high school, I would have replied. In high school, college, throughout my adult life. I probably would have told him that these depressions didn’t last forever, that there must have been interludes where I felt I could face the world, even if I was unable to recall them.

  • One thing I distinctly recall saying was that I felt agitated, as if an agitated depression were possible, I added. Then I punctuated my comment with an ironic laugh.

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    So here we are with major clues that my depression was probably closer to bipolar than unipolar. Can you take take a few guesses? Take your time ...

    Okay, here’s the indicators: Early first onset (more typical of bipolar); depressions that came and went, mostly of short duration (more typical of bipolar); agitation (a clear sign that this was not a pure depression, that there may have been mania features involved); laughter (I was able to react to surrounding events, an “atypical” feature fairly common to bipolar depressions).

    No doubt, I served up a lot more clues, and had my psychiatrist been more savvy his diagnostic radar would have locked in. Then he would have probed deeper into my past, looking for evidence of previous manias and hypomanias.

    “What happened when you left your last job?” he might have asked. I probably wouldn’t have given him a straight answer, but a few skilled follow-ups would have wormed the truth out of me.

    “Wait a second,” he might have cut in. “You mean, with hardly any money in the bank, with no job lined up, on your own in a strange country with the economy going south, you just up and quit your job for no good reason?”

    Don’t worry I might have responded in self-defense. You see, once I realized I couldn’t find another job I wrote a book in five weeks.

    (Game, set, match.)

    This is what Dr Sachs was talking about when he referred to depression acting as the pointer stars to mania and hypomania. Believe it or not, it works the other way around, as well, with our ups providing invaluable pointers into our downs, but that is the topic for another sharepost.


    Further reading from Knowledge is Necessity:

Published On: February 20, 2010