Mood Disorders and Different Kinds of Depression

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In any given year, nearlyone in 10 Americanadults will suffer from a

mood disorder. These ill-nesses involve changes inmood that affect daily life.They include major depres-sive disorder, dysthymia(persistent, low-gradedepression) and bipolardisorder (episodes of “low”mood that alternate withepisodes of “high” mood or

unusual levels of energy or activity). People with mooddisorders might have trouble with work life, family lifeand social life, or they might have difficulty simply get-ting through the day. While most mood disorders havedepression in common, only in bipolar disorder arethere mood swings of depression and periods of hypo-mania (if the bipolar disorder is mild) or mania (ifsevere). It’s important to know the difference betweenthe different types of depression, because differenttypes require different treatments.

What is Depression?Depression is more than just feeling sad. It’s a seri-ous—but treatable—medical illness characterized by animbalance of brain chemicals called neurotransmittersand neuropeptides. It’s not a character flaw or a sign ofpersonal weakness. Just like you can’t “wish away” dia-betes, heart disease or any other physical illness, youcan’t make depression go away by trying to “snap outof it” or “pull yourself up by your boot straps.” Early inpeople’s experience of a mood disorder, their episodesof depression often follow stressful events like maritalproblems or the death of a loved one. While depressionsometimes runs in families, many with the illness haveno family history of depression. The exact causes ofdepression—and mood disorders in general—still arenot clear. What we do know is that both genetics and a stressful environment, or life situation, contribute tothe cause of mood disorders. Usually, it’s not one orthe other, but a combination of both.

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An estimated 18 million or more Americans experiencea major depressive episode each year. It’s the leadingcause of disability for people ages 15–44 in the UnitedStates. And for the majority of people, it is a recurrentillness which can become chronic (lasting for morethan two years).

People who have recurrent episodes of major depressionare sometimes said to have unipolar depression (orwhat used to be called “clinical depression”), becausethey only experience periods of low, or depressedmood. Those living with chronic, low-grade depressionhave what is called dysthymia. When people experienceboth dysthymia and major depression, they are some-times said to have double depression. In addition,mood disorder symptoms can arise after a woman givesbirth (postpartum depression). And they also can beaccompanied by psychosis (psychotic depression) andcan occur during the winter season (seasonal affectivedisorder, SAD). However, what most mood disordershave in common are major depressive episodes.

Signs and Symptoms of Major Depressive Episodesn Prolonged sadness or unexplained crying spells n Significant changes in appetite and sleep patterns n Irritability, anger, worry, agitation, anxiety n Pessimism, indifference n Loss of energy, persistent lethargy, fatigue n Feelings of guilt, worthlessness or helplessness n Inability to concentrate, difficulty making decisionsn Social withdrawaln Inability to take pleasure in activities or hobbies

once pleasurable n Unexplained aches and pains, or aches and pains

that don’t ease with treatment n Recurring thoughts of death or suicide

What is Bipolar Disorder?Bipolar disorder is another type of mood disorder, dif-ferent from unipolar depression. People diagnosed withthis illness have mood swings involving both lows(bipolar depression) and highs (called mania ifsevere or hypomania if mild). It’s estimated that two

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to five percent of American adults will suffer some formof bipolar disorder.

When people go through the lows of bipolar disorder(bipolar depression), their symptoms are very similar tothose that someone with unipolar depression mighthave. In a severe case of bipolar disorder, people expe-rience extreme highs known as mania.

Signs and Symptoms of Manian Restlessness, increased physical/mental activity

and energy n Heightened or “high” mood, exaggerated

optimism and self-confidence n Excessive and extreme irritability, aggressive

behavior n Decreased need for sleep without feeling tired n Grandiose thoughts, inflated sense of self-

importance and abilities n Racing speech, racing thoughts, flight of ideas n Impulsiveness, poor judgment, distractibility,

inability to concentrate n Reckless behavior like spending sprees, drug use,

sexual indiscretionsn A period of unusual or uncharacteristic behavior n Denial that anything’s wrong n In the most severe cases, delusions and

hallucinations

Some people with bipolar disorder can experiencewhat’s called a mixed state. When this happens, peo-ple have symptoms of both depression and mania atthe very same time. Those who have had a mixed stateoften describe it as the very worst part of bipolar disor-der. They have all of the negative feelings that comewith depression, but they also feel agitated, restless and activated, or “wired.”

Just as there are different types of depressive disorders,there are also different types or patterns of bipolar dis-order, such as rapid cycling (more than four moodepisodes in one year), cyclothymia (mild highs andlows), and bipolar not otherwise specified (NOS).The two most common types are bipolar I and bipolar II.

Bipolar I disorder used to be called “manic depres-sive illness.” It’s the “classic” form of the illness in whichthe individual experiences extreme highs (mania) andlows (bipolar depression) in mood. In contrast, peopleaffected by bipolar II disorder don’t have suchextreme highs or manic symptoms. Instead, they expe-rience just mild highs, or hypomania. The symptoms ofhypomania are similar to those of mania, but much lessintense and severe. In fact, people who experiencehypomania might not feel impaired at all. For example,people who are hypomanic might be more talkativethan usual, but their speech makes sense and seems tofollow a logical pattern. They don’t experience halluci-nations or delusions. Hypomania might make themappear more energetic or productive. But if their illnessgoes untreated, they can become severely depressed.Those with bipolar II disorder tend to have moredepressive episodes than those with bipolar I.

In both types of the illness, though, bipolar depression(the lows) is more common than mania or hypomania(the highs). Bipolar depression is also more likely to be accompanied by disability and suicidal thinking andbehavior. One thing that all types of bipolar disorderhave in common is this: people with the illness spendthe majority of their symptomatic lives “below baseline”… in the low, depressed phase.

What’s the Difference BetweenUnipolar and Bipolar Depression?

The symptoms of unipolardepression and bipolardepression are very similar.The main difference is thatsomeone with unipolardepression doesn’t experi-ence the highs periods ofmania (if severe) or hypo-

mania (if mild). And this is extremely important,because the preferred treatments of the two can bequite different.

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Why Bipolar Disorder is Often MisdiagnosedBecause the illness has such a wide range of symptomsand behaviors, bipolar disorder can be misdiagnosed.It’s possible for bipolar disorder to “hide” and go unno-ticed, because patients and/or providers don’t recog-nize the highs. Many people actually see these highs asan idealized norm. To complicate things further, itmight be several years before a patient even experi-ences the highs.

Many people who are correctly diagnosed with bipolarI disorder were diagnosed during a crisis associatedwith full-blown manic behavior. But hypomania—themild highs experienced by those with bipolar II disor-der—is especially difficult to recognize. Hypomaniamight not have negative side effects for the individual atfirst. And sometimes, people actually function betterduring a hypomanic episode. They often see them-selves as being more productive.

Most people with bipolar disorder aren’t inclined toseek psychiatric treatment when they’re experiencingthe highs of mania or hypomania. In fact, many don’teven realize that the highs aren’t normal. Many folkswould like to keep their highs, because they feel outgo-ing, extroverted and friendly … like “the life of theparty.” The problem, though, is that periods of depres-sion eventually follow most highs. After episodes ofhypomania or mania, people begin to feel fatigued anddown. They become aware that they’re gradually slip-ping into depression. It’s during this “low” phase ofbipolar disorder—bipolar depression—that most peo-ple seek professional help and receive a diagnosis. Infact, the majority of people with bipolar disorder in theoutpatient setting are initially seen for—and diagnosedwith—unipolar depression. The highs they’ve experi-enced are ignored.

It’s estimated that many people with bipolar disorderwait about 10 years between their first contact with amental health provider and receiving the correct diag-nosis. Folks who have bipolar disorder along with alco-hol or drug use problems often go undiagnosed foreven longer: 15–20 years. Studies show that, in the primary care setting alone, 10–25 percent of people

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diagnosed with unipolar depression may actually havebipolar disorder. The percentage is even higher amongpatients in the psychiatric setting. And incorrect treat-ment for bipolar disorder can actually lead to episodesof mania and other problems.

What’s Different about Treatments for Bipolar Disorder and Unipolar Depression?

Treatment for bipolar disorder usually includescounseling (psychother -apy) and a medicationcalled a mood stabilizer.Counseling helps peoplelearn how to live with, ormanage, the leftover symp-toms of the illness. And

mood stabilizers prevent, or delay, future episodes ofdepression, hypomania or mania. Often, other medica-tions like traditional antidepressants are also necessary.

But for some people with bipolar disorder, taking a tra-ditional antidepressant alone, or along with a mood sta-bilizer, can make the illness worse by causing the symp-toms of hypomania to return. (This can happen to peo-ple with unipolar depression, too. Such cases, though,aren’t very common.) Antidepressants can sometimesalso make bipolar depression worse by causing suicidalthoughts. If that happens, the traditional antidepressantshould be discontinued immediately.

So that these things don’t happen, it’s important toknow whether someone’s depression stems from bipo-lar disorder or is instead unipolar depression. For thatreason, it’s important to see a mental health providerwho has experience distinguishing between “regular”unipolar depression and bipolar depression. With athorough medical and psychiatric history (including anypossible manic or hypomanic symptoms), as well as acomprehensive physical exam, these providers can re -duce the number of misdiagnoses. And this means peo-ple get the treatment they need … and get it sooner.

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How Do I Know If I Have Unipolar or Bipolar Depression?Even with excellent health care, sometimes bipolardepression can still be mistaken for—and misdiagnosedas—unipolar depression. Why? Because many peoplewith bipolar disorder only have recurrent episodes ofdepression during the early years of their illness. Thehypomanic or manic episodes often don’t start rightaway.

When people are misdiagnosed, treatment mightseem to work for only a short time, and then themood epi sodes return. Or maybe treatment doesn’twork at all. If you or a loved one has received morethan one adequate course of treatment for unipolardepression (including both counseling and medica-tion), and haven’t responded, ask your doctor to con-sider whether you may actually have bipolar disorder.Even the best and most experienced clinicians mightmake an incorrect diagnosis at first, because the highsdon’t always occur during the first few years of the illness. How you progress in your treatment will helpyou and your provider determine the next steps foryour recovery.

No clinician or tool can diagnose unipolar depressionor bipolar disorder with 100 percent accuracy. Bepatient with yourself and your health care provider. If you’re not getting better, make sure your providerknows this. Illnesses are sometime impossible to diag-nose right away. Research does point to some clues thatwhat’s mistaken for depression might actually be bi -polar depression—the depression phase of bipolar dis-order. Studies show that people incorrectly diagnosedwith unipolar depression often have

n the perception that “people are unfriendly”n a co-occurring anxiety disordern a recent (in the last five years), initial diagnosis

of unipolar depressionn a family history of bipolar disordern legal troubles

These signs could indicate that providers need toreevaluate your initial diagnosis, as well as screen forbipolar disorder. To do this, your doctor might ask you

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to take a short survey, like the Mood DisorderQuestionnaire (MDQ) found on DBSA’s website atwww.DBSAlliance.org/MDQ. The MDQ is a series ofquestions designed to help your health care providerdistinguish unipolar from bipolar depression. If you’re

not responding to your treat-ment, you might want to fillout the questionnaire andtake it to your next visit.Remember, only qualifiedhealth care providers candiagnose you. Your job is tomake sure that they have allof the information they needto treat you. Often, the bestway to get quickly and accu-rately diagnosed is to go to a

health care provider for an evaluation with a loved oneor significant other, someone you trust and who canshed light from a different perspective. Having some-one else with you during a first-time evaluationimproves your chances of getting the very best diagno-sis and treatment. It also helps your loved one learnabout, and understand, your illness.

Keep in mind, though, that if you’re not responding toyour treatment, it doesn’t necessarily mean you’ve beenmisdiagnosed. If your treatment isn’t working but youhaven’t had any symptoms of mania or hypomania, itmight be that you simply need a change in your dosageand/or type of medication or psychotherapy. Recentstudies show that many people who don’t start feelingbetter after one adequate course of antidepressants willbenefit from a different medication.

How Do I Talk to My Doctor AboutMy Diagnosis and Treatment?Many people are reluctant to talk to their doctor if theythink they might have been incorrectly diagnosed ortreated. They’re afraid their doctor will be offended orthink they’re questioning his/her expertise or authority.It’s important to remember, though, that the best treat-ment results from a partnership between provider and patient. This means that both of you are working

to gether to achieve the best possible results. The pro -vider is responsible for gathering and analyzing the nec-essary information. And you are responsible for provid-ing that information. The provider may be the experton the illness, but you are the expert on your life.

If you think you might have been incorrectly diagnosedor treated, talk with your provider about it. Be sure toinclude the specific reasons that you think this. A goodclinician will listen to you and address your concerns.The fact that you have concerns might mean that youwould benefit from further information or changes inyour treatment plan.

Hope, Help and SupportDepression and bipolar disorder are complicated ill-nesses with complex and challenging symptoms. Butit’s important to remember that you’re not alone, andthat there is hope, help and support. These illnessesare treatable, and treatment does work. The majority ofpeople who get diagnosed and treated experiencesome degree of recovery. Work together with yourhealth care providers to come up with the treatmentplan that is best for you. You might also considerattending a DBSA support group, where people withmood disorders and their loved ones can share experi-ences, discuss coping skills and offer hope to oneanother. In time, with treatment and support, you’ll see that recovery is possible.

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The Depression and Bipolar Support Alliance (DBSA) is the leading patient-directed national organization focusing on themost prevalent mental illnesses. The organization fosters an environment of understanding about the impact and manage-ment of these life-threatening illnesses by providing up-to-date,scientifically based tools and information written in language thegeneral public can understand. DBSA supports research to pro-mote more timely diagnosis, develop more effective and tolerabletreatments and discover a cure. The organization works to ensurethat people living with mood disorders are treated equitably.

Assisted by a Scientific Advisory Board comprised of the leadingresearchers and clinicians in the field of mood disorders, DBSAhas more than 1,000 peer-run support groups across the country.Nearly five million people request and receive information andassistance each year. DBSA’s mission is to improve the lives ofpeople living with mood disorders.

Depression and Bipolar Support Alliance 730 N. Franklin Street, Suite 501Chicago, Illinois 60654-7225 USAPhone: (800) 826-3632 or (312) 642-0049Fax: (312) 642-7243Website: www.DBSAlliance.org

Visit our updated, interactive website for important information,breaking news, chapter connections, advocacy help and much more.

This brochure was reviewed by DBSA Scientific Advisory Board memberJoseph R. Calabrese, MD, professor of psychiatry at Case WesternUniversity and director of the University Hospitals of Cleveland's MoodDisorders Program. DBSA Director of Scientific Affairs Brenda Bergeson,MD, also reviewed this publication.

DBSA does not endorse or recommend the use of any specific treatment, medication or resource mentioned in this brochure. Foradvice about specific treatments or medications, individuals shouldconsult their physicians and/or mental health professionals. Thisbrochure is not intended to take the place of a visit to a qualifiedhealth care provider.

©2008 Depression and Bipolar Support Alliance MD1208

Models used for illustrative purposes only.

We’ve been there. We can help.