THE BIPOLAR SPECTRUM
For about half a century, psychiatry divided mood disorders into cases of unipolar depression, an illness in which only depressive symptoms characterize the illness, and bipolar disorders, in which patients suffer from depressive episodes but also manic, hypomanic or mixed states as well. Bipolar spectrum disorders seem to challenge this way of thinking; these patients very frequently have an illness that is dominated by depression symptoms and that shows only the slightest colorings of mania. They may have periods of elevated mood that they don’t feel are particularly abnormal but which, when examined more closely, bear the hallmarks of hypomania: decreased need for sleep, increased energy, uncharacteristic overconfidence and loss of inhibitions. As mentioned previously, periods of agitation and irritability that last only a few hours may represent mild mixed states that mark a case of severe depression as a soft bipolar disorder. I have seen many patients who have been unsuccessfully treated with antidepressant after antidepressant for what they have been told is “unipolar depression.” Many of these patients have bipolar features to their illness that haven’t been recognized as such. When one of the medications more typically used to treat bipolar disorder is prescribed for them, these patients frequently have a significant improvement in their depressive symptoms.

I have had patients with this kind of problem become upset when I try to explain that a better treatment approach for their depression problem might be to treat it as a form of bipolar disorder; they worry that a diagnosis of bipolar disorder means that they have a more serious problem than “just depression” or are “really crazy.” This overlooks the several facts. First, that depression is always a serious illness and second, that many people with bipolar disorder never develop full blown mania or psychotic symptoms (which is what most people are thinking of when they use the pejorative term “crazy.”) I sometimes use the term “complicated depression” to talk about these illnesses.

The important point to remember is that, despite what you might gather from the reading short newspaper or magazine articles about depression and bipolar disorder, we haven’t yet figured out how to classify these illnesses. It is becoming clear that many cases that seem to be “just depression” are related in some way to bipolar disorder. Many depressed patients who don’t seem to have classic “manic-depressive illness” will nevertheless benefit from medications used to treat bipolar disorder."

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