By Donna Jackel

 

It is the manic phase of bipolar disorder that attracts—no, demands—attention. But those who have the illness, or love someone who does, know it is depression that most disrupts and devastates lives—and dominates the course of the illness.

“Few people understand [that] depression sucks the life out of you,” says C.A., 52, of Oregon. “Desires, self-esteem, motivation, self-worth—any of those qualities that keep you going in life—disappear.” Since her 2002 bipolar diagnosis, she has gone only 18 consecutive months without depression.

When P.S. of Halifax, Nova Scotia, is sad, she sometimes avoids bike riding with her seven-year-old daughter. The guilt she feels at withdrawing from her child only intensifies her depression.

“You look at the functional outcomes, such as the ability to work, family life, being an active participant in society—this is largely driven by depressive, rather than manic, symptoms,” notes Roger S. McIntyre, MD, associate professor of psychiatry and pharmacology at the University of Toronto, and head of the Mood Disorders Psychopharmacology Unit at the University Health Network in Toronto.

One reason depression is more debilitating than mania is that it lasts longer; another is that it occurs more frequently: According to a 2002 study by Lewis L. Judd and colleagues at the University of California at San Diego published in the Archives of General Psychiatry, people with bipolar I experience depression three times as often as mania. For bipolar II, the ratio of time spent in depression versus mania is a whopping 40:1.

Bipolar depression is also difficult to diagnose, and therefore to treat. Some studies suggest that as many as 50 percent of those with bipolar disorder are misdiagnosed with unipolar depression, according to Michael E. Thase, MD, professor of psychiatry at the University of Pennsylvania School of Medicine and author of several books on bipolar, depression and related topics.

It’s not surprising that misdiagnoses frequently occur. The Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV), doesn’t distinguish between bipolar and unipolar depression. Rather, a bipolar diagnosis is made based upon whether the person has experienced mania or hypomania.

People with bipolar I experience depression three times as often as mania.

“Bipolar depression looks very similar to major depression, with no distinct features,” says McIntyre. “That being said, people with bipolar depression more often complain of symptoms that are atypical for unipolar depression, including increased eating, sleeping, and profound reduction in energy. Moreover, people with bipolar depression also frequently complain of seasonal worsening and ‘therapeutic misadventures’ with antidepressants—that is, the depression gets worse with antidepressant therapy.”

Because bipolar and unipolar depression can “look” so similar, psychiatrists must take care to get detailed family histories—and to ask patients if they have ever experienced symptoms of mania or hypomania, says Eric D. Caine, MD, chairman of psychiatry at the University of Rochester Medical Center and an international expert on suicide prevention. Otherwise, “the tendency is to treat it as if it’s unipolar depression, with antidepressants alone, which may serve as rocket fuel for a manic episode,” he adds.

 

How it feels

How does one experience bipolar depression? That depends upon whom you ask. Many people undergo distinct periods of stability, mania, and depression. Yet other individuals can feel both depressed and manic at the same time—simultaneously feeling very sad and energized.

Holly A. Swartz, MD, associate professor of psychiatry at the University of Pittsburgh School of Medicine, says it is relatively rare for people to meet the DSM-IV criteria for a mixed state, which requires a major depressive episode and a manic episode nearly every day for at least one week. “However, individuals meeting diagnostic criteria for either a depressive episode or a manic episode often have a few subsyndromal symptoms of the opposite pole of the disorder that co-occur with their predominant mood episode,” Swartz says. “For example, someone will meet full criteria for a depressive episode but will also have racing thoughts.”

Rapid-cycling—as defined by the DSM-IV diagnostic criteria—is having at least four distinct episodes of major depression, mania or hypomania, or mixed symptoms within a 12-month period. But it is possible to experience more than one rapid-cycling episode a week, or “even within one day,” according to the National Institute of Mental Health.

Just because you are feeling down when you wake up and hypomanic later in the day, however, doesn’t mean you are rapid-cycling, emphasizes Joseph R. Calabrese, MD, director of the Mood Disorders Program at Case Western Reserve University in Cleveland. He says consumers often confuse mood lability [instability] with rapid-cycling. Only about 15 to 20 percent of people with bipolar experience rapid-cycling, he adds.

Jennell A., 53, of The Villages, Florida, says her moods shift quickly—sometimes from one hour to the next.

“Yesterday morning, I woke up at 5:30 a.m. and by 8:00, I knew I was in a hyper-manic cycle,” she says. I was running around nonstop, never stopped talking, and felt like I was running a marathon all day.” But the next morning, Jennell, who awoke early for a golf date, felt like she was “in a fog.” “I knew I could either get up and get going, or spiral into the depressed side of me. I went golfing!”

 

Triggers

As with mania, knowing what stressors leave you vulnerable to depression can help prevent recurrences. Lack of sleep, work-related stress, and traumatic events can all be triggers. For T.L.’s husband, holidays are particularly difficult—they stir unhappy childhood memories. Vacations are also potential land mines.

“After a couple days, he becomes extremely irritable and annoying,” says T.L., who lives in Wayne, New Jersey. “He can’t relax, which is no vacation for either of us! It seems to have to do with breaking out of his work routine and structure. Even on weekends, he tends to be more symptomatic.”

Then there are the stress factors beyond one’s control—such as ill health or the death of a loved one. “The economy has greatly affected our finances and our work situations,” says Therese J. Borchard, a mother of two, popular blogger (Beyond Blue on beliefnet.com), and author of several books, including the memoir, Beyond Blue: Surviving Depression & Anxiety and Making the Most of Bad Genes (Hachette Book Group, 2009). “It has taken about nine months to navigate through that stress, but now that we have found a way to produce enough income, I think I will be less prone to fall into depression.”

 

Keeping things steady

The severity of the illness, one’s support system, the luck—or failure—of finding effective medication, a competent doctor, and a supportive partner—all affect how successfully bipolar depression can be stabilized. Muriel H. of Easley, South Carolina, managed to teach for 32 years, in part because of her husband’s steady encouragement, but some days it took all her inner resources to make it through the day.

“Had it not been for my work ethic, I would have been home in bed,” Muriel says. “On many weekends, I would hole up in my apartment, not coming out again until Monday morning.”

Severe bipolar depression not only robs one of the ability to enjoy life, but also may even interfere with basic acts of self-care. C.A. lives directly across the street from a grocery store, but recalls one morning when even that short distance was too far to walk. She showered, applied some makeup, but found she couldn’t leave the house. “I stood at my bedroom window, looking across the way at the store and crying. I felt helpless and stupid.”

It is when we are in absolute despair that we most need the comfort of loved ones. The irony is this is also the time when we feel the most unlovable, are least able to return love, and tend to strain the devotion and patience of even the most steadfast caregiver.

T.L. knows her husband’s depressed when he grows quiet, turns from sweet to “snappy,” has trouble sleeping, becomes overly critical, and begins obsessing over trivial things, like irritating TV commercials. As soon as she observes such symptoms, T.L. asks her husband how he’s feeling and whether anything is stressing him out.

“One time, I was on the computer and he came down to the office to say good night. I was in the middle of writing an email. He gave a big sigh, stomped up the stairs, and slammed the bedroom door. I went up and calmly asked what his problem was, and he snapped something about not kissing him goodnight … as if I could read his mind. I quickly realized this was an [irrational] conversation, told him so and to get some sleep, and we could have a rational conversation the next day, which we did.”

 

The darkness of despair

When the darkness doesn’t lift, despite the help of family and modern medicine, many people lose all hope. According to the National Mental Health Association, 30 to 70 percent of suicide victims suffered from major depression or bipolar disorder. And a 2000 study conducted by researchers at Johns Hopkins University found that approximately 25 to 50 percent of patients with bipolar attempt suicide at least once.

The light in the seemingly endless darkness of depression is that people do recover and rebuild their lives.

A mixed state can place a patient at particularly high risk of suicide, says Caine of the University of Rochester. “In a mixed state, someone has the thinking and motor features that are much more like someone on the manic end of things,” he says. “But you can also be very suicidal then. It’s a time of impulsivity and very rapid actions. It may appear like suicide is sudden, but the person may have been thinking about it for a long time, and now they have the fuel to do it.”

The trick for doctors and caregivers is not to be fooled by body language—someone in a mixed state can be smiling and standing straighter, yet still be capable of suicide.

 

Self-help

Having a plan in place can help prevent minor symptoms from turning into a full-blown episode, says psychologist Elizabeth Saenger, PhD, an assistant professor at Columbia University’s department of psychiatry. She suggests: “Work with a mental health professional to put together a plan: ‘How will I recognize when I am beginning to get depressed? How will my family?’” Saenger also recommends enlisting a trusted friend or family member who isn’t afraid to tell you, “I think you should go to the doctor.” And then do it.

Jennell has a rich support system—a caring husband who will play cards with her for hours to distract her from her depression, a therapist she sees every other week, and a psychiatrist she visits monthly. She also has her faith.

“God plays an important part in my life in everything I do,” Jennell says. “Having that as my main support gets me by.”

P.S. of Halifax says her psychiatrist is the “one constant” in her life. “I really rely on her. I respect her opinion. If she tells me to back off—that I’ve taken on too many projects—I might argue some, but eventually I realize she’s right.”

The light in what can—at times—seem like the endless darkness of depression, is that people do recover, find medications that work, and rebuild their lives. Two years ago, Borchard would have said that her depression “got in the way of everything.” Not anymore.

“Today I can honestly say that my illness has made me a better spouse, mother, and worker because I’ve had to learn how to use an incredible amount of discipline with just about everything: from sleeping to eating to exercising and communication, to workload and relationships,” Borchard says. “I take every step of life with much more deliberation and care. If I get lazy, it could literally cost me my life because my illness needs healthy relationships and healthy life habits.”

 

*   *   *   *   *

 

Depression Symptoms

MAJOR DEPRESSIVE DISORDER

• Feelings of hopelessness, pessimism
• Feelings of guilt, worthlessness, helplessness
• Difficulty concentrating
• Loss of interest or pleasure in hobbies and activities that were once enjoyed
• Difficulty sleeping
• Overeating or loss of appetite
• Persistent aches or pains, headaches, cramps or digestive problems that do not ease even with treatment
• Thoughts of suicide, suicide attempts

BIPOLAR DISORDER

• Feelings of hopelessness, pessimism
• Feelings of guilt, worthlessness, helplessness
• Difficulty concentrating
• Loss of interest or pleasure in hobbies and activities that were once enjoyed
• May experience sleep disturbances, or oversleeping
• Overeating or loss of appetite
• Persistent aches or pains, headaches, cramps, or digestive problems that do not ease even with treatment
• More suicide attempts than with major depressive disorder
• A profound loss of energy
• Severe depression more likely to include psychotic symptoms
• Onset of depression occurs at a younger age
• More likely to have a co-occurring mental illness, such as obsessive-compulsive disorder, panic disorder, or substance abuse
• More likely to have a family history of mania
• More episodes of depression than with unipolar depression
• Use of antidepressant—without mood-stabilizer—may cause hypomania or mania

 

*   *   *   *   *