Psychology Tutor: Mentor (PSI) Psycho-Social Incarnation

Concern has been expressed by some psychiatrists that Bipolar disorder is being severely under-diagnosed in patients presenting with depression. Bipolar disorder is a very common mental illness, but despite its increased profile in recent years due to the number of ‘celebrity sufferers’, it is still often overlooked by practitioners who are assessing patients with depression. It may be useful to re-acquaint yourself here with the symptoms of Bipolar disorder, so that it is in your mind when considering a patient presenting with depression.

Type I Bipolar Disorder

Type I Bipolar disorder used to be known as ‘manic depression’. This is far easier for doctors to spot because the symptoms are extreme and fairly clear-cut. The patient’s mood can change from deep depression to wild elation, and extreme, destructive behaviour. During the manic phase of the illness symptoms include grandiosity and a feeling of being all-powerful. The patient may clean out their current accounts in reckless spending sprees, or seek other extremes to sustain the (often enjoyable) high they find themselves in. Practitioners should be aware of the patient’s drug habits, however, since some forms of drug use (heavy use of cocaine and amphetamine) can mimic the symptoms of the manic phase. The picture is complicated, since as many as 80% of bipolar sufferers will be drug users, and it takes a skilled assessment to sort out the symptoms. The delusional nature of the manic phase, and the undoubted enjoyment that can accompany it for some, makes it unlikely that sufferers will ask for help during an episode. Part of this is their lack of insight into their condition, due to the delusions of powerfulness and invincibility. Their fixed false beliefs mean that they simply cannot recognise what they are doing is not normal.

Type II Bipolar Disorder

In Bipolar Type I then, symptoms are fairly clear-cut. There are manic highs, with disordered behaviour, and there are depressive lows. But Bipolar Type II is more subtle, and harder to spot. Patients usually present to their doctor in the depressive phase, often leading to a diagnosis of simple clinical depression. Depression is the most common and pervasive symptom of Bipolar Type II, and the ‘manic’ phases are less extreme in Type II Bipolar. When the depression lifts, a heightened mood is seen as a natural consequence of this, and overlooked. But the highs often include risk-taking behaviour, such as drug abuse, promiscuity or alcohol abuse, which in turn contribute to the recurrence of the depression. These mood shifts – known as ‘cycles’ – can be rapid, sometimes several in a day or a week – and this is another reason that clinicians miss the symptoms of Bipolar Type II. It would be easy to dismiss Bipolar II as a ‘milder’ version of ‘manic depression’. The opposite is in fact true. Research has shown that Bipolar II sufferers have been shown to have worse outcomes over their lifetime, and be much more at risk of suicide than Bipolar I sufferers. It is certainly not an illness to be ignored. Let’s summarise the list of symptoms here for quick reference:

Bipolar Symptoms – ‘Manic’ phase

• A heightened sense of self-importance or ‘grandiosity’
• An exaggerated positive disposition
• A decreased need for sleep, and difficulty sleeping
• Poor appetite
• Weight loss
• Racing speech, thoughts and flights of ideas
• Impulsive, risk-taking behaviour – excessive drinking, promiscuity etc
• Poor concentration and easy distractibility
• Vastly increased activity level
• Excessive involvement in pleasurable activities
• Poor financial choices and ill-advised spending sprees
• Excessive irritability
• Aggressive behavior

Bipolar Symptoms – ‘Depressive’ phase

• Deep feelings of sadness or hopelessness
• A loss of interest in pleasurable activities
• No longer interested in previous interests
• Difficulty in sleeping
• Early-morning waking
• A loss of energy; constant lethargy and low activity
• Feelings of guilt; low self-esteem
• Difficulty concentrating; memory loss
• Negative thoughts about the future
• Weight gain; weight loss
• Thinking or talking about suicide or death

This is only a basic guide to a commonly overlooked disorder, but salutary nonetheless. The nature of bipolar disorder is complex, but it is clear from research that biological factors are decisive. The drug of choice used to be lithium, but great steps forward in treatment are being made at present, with an increased emphasis on using anticonvulsant medications. Doctors noticed improvements in mood-stability in patients being treated for epilepsy and migraine. The use of drugs such as Lamictal and Depakote in treating bipolar depression have proved effective. Anticonvulsant medication calms hyperactivity in the brain and are highly effective in treating the manic phase of bipolar disorder. Anticonvulsant medication currently used to treat bipolar disorder are:

• Depakote, Depakene (divalproex sodium, valproic acid, or valproate sodium)
• Lamictal (lamotrigine)
• Topamax (topiramate)
• Trileptal (oxcarbazepine)
• Gabitril (tiagabine)
• Tegretol (carbamazepine)

According to The Bipolar Foundation, bipolar disorder affects:

‘…up to 254 million worldwide, 12 million in the US and 2.4 million people in the UK, and is a major cause of suffering and suicide. The World Health Organization has identified bipolar disorder as one of the top causes of lost years of life and health in 15-44 year olds, ranking above war, violence and schizophrenia.’

These are sobering statistics, and certainly not a picture of the ‘trendy celebrity illness’, as some some dismiss it. In the words of psychiatrist Dr Alan Ogilvie, CEO of the Foundation:

“Bipolar disorder is a much neglected and potentially lethal problem which is ignored, frequently unrecognised, poorly treated and ruins the lives of many. This is tragic when a lot already can be done to help if it is spotted early and treated”.