Is Your Unipolar Depression Really Bipolar Waiting to Happen?

Patient Expert

In a recent post, I traced the history of our understanding of bipolar disorder. This has tremendous implications for those of you who suffer from unipolar depression. This is because back in the past, what we used to call manic-depression also included unipolar depression.

Yes, there were some diagnostic outliers such as "depressive neurosis," but let's save that for another time.

In the 1950s and 60s, researchers began making the case for a split into what they began to describe as unipolar and bipolar. The DSM-III of 1980 made this official and in the process retired the term manic-depression.

But this separation came at a price. As Goodwin and Jamison point out in their second edition to Manic-Depressive Illness (2007), the DSM created the wrong impression that neither condition bore any relation to the other.

The reality is far different, characterized by considerable overlap. What does the overlap look like?

Goodwin and Jamison refer to "highly recurrent depression." These are individuals in the course of experiencing at least their third episode. Conventional psychiatry would have you disregard those first two depressions and not recognize the strong possibility of a fourth.

Goodwin and Jamison, on the other hand, ask us to look at these supposedly separate episodes as part of the same phenomenon. To understand this, we need to know how bipolar works.

In bipolar, the patient cycles from depression to mania or hypomania (mania lite) with intervals of "normal." Since these cycles repeat, those normal states are part of the disease process.

Perhaps you can see where we are going: As many as one-third of unipolar patients may also be cycling, only their "ups" top out at "normal." Then - sooner or later - the cycle drops them back down into depression.

In this sense, those with highly recurrent depression have more in common with their bipolar cousins than with other unipolars. Which raises this provocative question: Can certain types of unipolar actually be bipolar waiting to happen?

In a study published in 2005, the Swiss psychiatrist Jules Angst and his colleagues tracked 406 patients with major mood disorders over a 20-year period. Of those presenting with depression, four in ten eventually manifested as bipolar.

This translates to a yearly switch rate of between .5 and one percent, which may explain why no one is exactly screaming from the rooftops.

Your doctor may be fully aware of highly recurrent depression, but may come to the entirely wrong conclusion that you need to stay on antidepressants forever in order to prevent future depressions.

Dr Goodwin questions the value of antidepressants in the first place, as these meds - without an accompanying mood stabilizer - are strictly verboten for bipolar patients. In bipolar, it is well established that antidepressants may induce mania and speed up cycling.

Recall, we are talking about a type of unipolar depression that behaves like bipolar. So it could be that antidepressants are making your depression worse and your condition unstable. And it could be that you would be better off on bipolar meds, instead, or even no meds.

Unfortunately, drug companies are not exactly rushing to conduct clinical trials on this population, but Dr Goodwin does mention that old studies of lithium - the original bipolar med - have proved useful on depressed populations.

Essentially, we are treating the cycle rather the episode.

A good psychiatrist will probe for evidence of past depressions, plus age of first onset (below age 30), plus family history (a relative with bipolar?), plus lack of response to at least two antidepressants, and more.

Needless to say, this is far beyond the competence of your family physician, who may have prescribed you an antidepressant after asking you just one question.

And of course, you will need to do your own research. I suggest starting with Jim Phelps' 2006 book, "Why Am I Still Depressed?"

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