MHM Magazine

Why is recognition of Bipolar Depression important? Recognising bipolar depression in patients is crucial as untreated episodes increase the risk of attempted and completed suicide in patients. An accurate diagnosis also guides medication choices for optimal outcomes. Primary care providers, as first responders, play a critical role in the detection and management of bipolar disorder for effective outcomes to be possible. Accurate diagnosis can also be vital in identifying co-occurring conditions and assisting patients in understanding their treatment options. Bipolar disorder is relatively common, affecting 2.8% of the adult population. While Bipolar I Disorder is equally prevalent in males and females, Bipolar II Disorder is more commonly diagnosed in females. The age of onset of Bipolar disorder is late adolescence into early adulthood. The average time it takes for a patient to reach a correct diagnosis is ten years, indicating the complexity of the diagnosis. Bipolar Disorder is a chronic illness with remissions and exacerbations arising even when patients are on medication, with 50% of their time being unwell. How Bipolar I and II present in patients also differ. In patients with Bipolar II, more time is spent unwell, with the predominant mood state being depression. In Bipolar I Disorder in comparison to Bipolar II the mood state is more frequently elevated. Patients living with Bipolar Disorder have significant and chronic interpersonal and occupational difficulties. The completed suicide rate in these patients is approximately 10%, with attempts of suicide falling in the 30% - 50% region. Suicide attempts are increased in patients presenting with mixed depressive states. Significant functional and cognitive impairments are associated with untreated lengthy episodes of Bipolar Disorder. Misdiagnosis 60% of patients who go on to be diagnosed with Bipolar Disorder initially are misdiagnosed with Unipolar Depression, specifically those presenting with Bipolar Depression. The reasons for misdiagnosis vary. Firstly, there seems to be an incomplete understanding of Bipolar Disorder by healthcare professionals. Bipolar disorder that presents first with a depressive state is often overlooked, especially in patients with no history of mania. There is also, at times, a failure to differentiate symptoms that can help differentiate Unipolar and Bipolar depression. Misdiagnosis has many consequences and direct implications for adequate and relevant treatment. Consequences include the inappropriate use of antidepressant agents, lending itself to an increased acute risk of switching from depression to mania or hypomania, and a delay of proper treatment. Often if an antidepressant is prescribed for these patients, they may initially get well, and after that, it may ‘stop working’. Diagnosis Making an accurate diagnosis of bipolar depression entails knowing the DSM 5 criteria of a major depressive episode, which includes five symptoms for at least two weeks (one needs to be a depressed mood or anhedonia). Exploring a patient’s history of a past manic or hypomanic episode or atypical responses to antidepressants plays a crucial role in diagnosis. A helpful mnemonic screening tool for bipolar depression or the presence of Bipolarity is WHIPLASHED. This tool can be used in all patients presenting atypical signs or poor treatment response to typical antidepressant pathways. The more WHIPLASHED features the patient has, the higher the Dr Antoinette Miric Psychiatrist Johannesburg UNDERSTANDING AND MANAGING BIPOLAR DEPRESSION Issue 5 | 2023 | MENTAL HEALTH MATTERS | 9 MHM