Depression or soft bipolar disorder?

Written by Kylie Hughes for psychiatric practitioner Dr. Robin Stone, M.D. for her medical blog.

Depression is among the top three causes of death and disability in the US (Michaud et al 2006).  Consequently, primary care providers spend an increasing amount of time diagnosing and treating mental health disorders.  Most patients seeking help for mental health issues will turn to their primary care doctor before approaching a specialist.

A recent study in The Lancet reveals the difficulties primary care doctors encounter in properly diagnosing depression (Kelly 2009).  This is not a criticism of primary care providers.  Rather, it highlights that mental health disorders can present with many different symptoms and phases.

It is concerning, however, that studies reveal that up to 50 percent of patients diagnosed with recurrent depression have features of mild hypomania, considered the ‘soft’ end of the bipolar spectrum.  Clinical research suggests that these patients might be more effectively treated within the framework of bipolar II disorder (Smith 2009).

Hypomania can be difficult to identify because it’s less pronounced than mania.  Patients can be unaware of the cycling nature of their mood, and only seek treatment when they’re feeling depressed.  As a consequence, patients can be misdiagnosed with depression for years (sometimes decades) before receiving proper diagnosis and treatment.  Again, this is not a criticism of primary care providers—bipolar disorder is a complex condition that tests every clinician’s diagnostic acumen and treatment skills.  This is especially so for ‘soft’ bipolarity.

What are the consequences of misdiagnosing bipolar II disorder as major depressive disorder?  In addition to delayed recovery, the primary concern is that antidepressant medications may carry a risk of worsening some patients’ symptoms.  ‘Antidepressant monotherapy for bipolar depression—at least for some patients—can cause more frequent mood episodes, mood destabilization, and possibly an increase in suicidal behaviors’ (Smith 2009).

Patients who are not feeling improvements within a few of weeks of beginning antidepressant therapy should seek specialty care.  Diagnosis of bipolar II disorder demands detailed psychiatric assessment.  Clinician’s are also encouraged to seek a corroborative history from a close relative of the patient to help identify if hypomania is present.  Most bipolar II patients will require a multi-modal therapy approach, including psychotherapy.

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