Depression in Bipolar Disorder – Diagnosis and Treatment
We have talked about hypomania and mania but I haven’t said anything yet about depression. It is very common in bipolar disorder and often follows right on from a period of mania or hypomania. It is as though the patient crash lands into depression. The higher you were the worse is the fall into depression. Bipolar depressions can last a year or even indefinitely if untreated and often notoriously hard to treat. By this I mean that sometimes they do not get better in response to therapy or several medications and great persistence is needed by the patient and psychiatrist working closely together to identify what works.
On the plus side depressions are much easier to recognize than hypomania and so treatment can begin earlier than would otherwise would be the case. They have basically have quite similar symptoms as standard major depression but with some distinct features of their own. So the typical constellation of symptoms includes: low mood, lack of interest, lack of pleasure, insomnia or hypersomnia, lack of appetite or excessive appetite, low energy, low drive, lack of libido, poor concentration, feelings of guilt, agitation or being slowed down in movement and thinking.
Some distinct features that are commonly but not always present in bipolar depression can be overeating and oversleeping and a lot of sensitivity to perceived criticism (this is called rejection sensitivity). The reason that bipolar depressions are particularly difficult to treat is that antidepressants do not appear to not work very well in these depressive episodes. Instead a whole other class of medications called mood stabilizers are the first line treatments.
There are a large number of mood stabilizer medications. They include Lithium, Lamictal (lamotrigine), Tegretol (carbamazepine), Trileptal (oxcarbazepine), Depakote (valproate), Seroquel (quetiapine), Abilify (aripiprazole), Latuda (lurasidone), Zyprexa (olanzapine), Symbyax (olanzapine-fluoxetine), Geodon (ziprasidone). As you can see it is a long list (10 medications at least) and it takes a lot of skill on the psychiatrist’s behalf in collaboration with the patient to work out what might be the best treatment in an individual case.
