False Unipolars and Hidden Bipolars: Are You One of Them?

Patient Expert

I have been hard at work on a book on bipolar disorder. How this applies to those of you with a diagnosis of major depression is simple - there is a fairly good chance that you are bipolar-waiting-to-happen.

Do I have your attention?

Goodwin and Jamison in the 2nd edition to  Manic-Depressive Illness  (2007) raise the issue of "false unipolars." In a 2013 editorial in the International Journal of Bipolar Disorders, Jules Angst - the man who came up with the term "unipolar" back in the sixties - reported that 40 percent of those diagnosed with major depression are contending with "hidden bipolar."

According to Dr Angst, in earlier writings, if we were to loosen the diagnostic criteria for hypomania (mania lite), those with bipolar would comprise somewhere between four to seven percent of the general population rather than just one to two.

To accomplish this would require rediagnosing all those false unipolars and hidden bipolars. The million-dollar question: Could you be one of them?

Goodwin and Jamison identify a population of those with "highly recurrent" depression. This population, which may comprise one-third of those diagnosed with unipolar major depression, essentially experience one depression after another separated by periods of remission.

If we reconceptualize "normal" as a mild state of "up," the pattern is virtually identical to the mood cycles that are a hallmark of bipolar. Indeed, Goodwin and Jamison make a strong case for including recurrent depression in the "bipolar spectrum." Other experts, such as Hagop Akiskal of UCSD, go a step farther by advocating a complete name change, say to "bipolar III."

All that differentiates "bipolar I" from "bipolar II" is the severity of "up." In bipolar I, the diagnostic threshold is mania, in bipolar II hypomania. In a new bipolar III classification, up would simply be higher than down.

Let's not quibble about how high up needs to be. We are simply looking for depressions broken up by lucid intervals. These depressions may be years apart. Someone who has experienced two depressions has a 70 percent chance of experiencing a third. For those going through their third depression, the odds of a fourth go to 90 percent.

This is very different from "chronic" depression, about which we have very little understanding.

In a study published in 2005 in the Journal of Affective Disorders, Dr Angst and his colleagues found that four in ten patients with depression eventually manifested as bipolar over a 20-year period. In a similar study, Dr Akiskal et al found a 12 percent increase over 10 years.

One reason it is so difficult to correctly diagnose bipolar in the first place is that it is virtually impossible to recall our "ups" when we are depressed. But perhaps you remember other times when you were down. An enlightened psychiatrist will see this as a red flag and probe deeper.

Another red flag - one pointed out by Goodwin and Jamison, Angst, Akiskal, and others - is your response (or lack of) to antidepressants. If you're like me, an antidepressant may have flipped you straight into mania. So it was that my diagnosis of unipolar major depression lasted all of two days.

My life infinitely improved once I had the right diagnosis and the right treatment.

Others aren't so lucky. The antidepressant may seem to work well in the short term, only to worsen over the long haul. The doctor may interpret the short-term effect as an encouraging sign, and try you on another antidepressant, then another.

This typically goes on for years. According to NIMH-underwritten STAR-D clinical trials in the mid-2000s, if your first two antidepressants have not made you well, there is very little chance of achieving a desirable outcome on a third.

Common sense tells us this is when we should revisit the original diagnosis. After all, you have had more time to recall past ups and downs and your doctor now has more to go on. Who knows your true diagnosis at this stage? This is why - now, more than ever - we need to be asking questions.

See also:

Is Your True Diagnosis Bipolar?

Bipolar Waiting to Happen?