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Tried everything but still not feeling better?

If your depression keeps coming back or is even getting worse, then you may be suffering from bipolar II or "soft" bipolar disorder. Commonly misdiagnosed, these mood disorders are characterized by recurring bouts of depression along with anxiety, irritability, mood swings, sleep problems, or intrusive thoughts.

Why Am I Still Depressed? shows you how to identify if you have a nonmanic form of bipolar disorder and how to work with your doctor to safely and effectively treat it.

Author James R. Phelps, M.D., gives you the latest tools and knowledge so you can:

• Understand the Mood Spectrum, a powerful new tool for diagnosis
• Know all your treatment options, including mood-stabilizing medications and research-tested psychotherapies
• Examine the potential hazards of taking antidepressant medications
• Manage your condition with exercise and lifestyle changes
• Help family and friends with this condition understand their diagnosis and find treatment

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Why am I still depressed?

McGraw-Hill

Contents

Chapter One

Most mood experts agree that many people have symptoms that represent more than depression, but less than bipolar disorder. But the official rule book of psychiatric diagnosis, the Diagnostic and Statistical Manual of Mental Disorders (DSM) has no place for these folks. So a new system has been growing alongside the DSM approach. Actually, this "new" system is quite old; it just seems new because of how we doctors have been doing diagnosis for the last fifty years. In this emerging way of thinking, diagnoses like depression and bipolar disorder are seen as the ends of a spectrum (as seen in Figure 1.1), and people can be found all along this continuum.

As you can see, at one end is unipolar depression (which the DSM calls Major Depression), and on the other is bipolar (which we're going to examine in more detail shortly). But what, you may ask, happened to manic-depressive? The condition formerly called manic-depressive disorder is the most extreme form of a whole group of mood conditions now referred to as bipolar disorders. This condition is characterized by mania, which can include delusions, hallucinations, paranoia, and all sorts of problem behaviors. Whoa, stop right there! This book is not about mania, OK? It is about the rest of the Mood Spectrum, which by definition does not include mania.

Understanding the Middle of the Mood Spectrum

Because most people think of mania when they hear "bipolar disorder," the idea that a person might have something related to bipolar disorder, even if so mild as to be nearly at the other end of the spectrum, is frightening. You might react to the idea by saying, "Me? Hey, I know what manic means, and I know I've never had that." But you may not know about all the other bipolar versions in the middle of the Mood Spectrum. You may only know about the most extreme form of bipolar disorder and not the subtle variations that can look much more like plain depression.

Wow, that's a lot of terms already: unipolar, major depression, bipolar, manic, and bipolar variations. Does it matter that much what you call it? Oh, definitely, and here's why. Antidepressant medications can make bipolar disorder worse. They can cause people to have a manic episode, including not only the positive, or euphoric, version where you feel "on top of the world," very confident, and full of potential, but also the negative, or dysphoric, version where you feel agitated and angry, and believe that the people around you are stupid, slow, and pathetic.

Negative version of mania? This may be a new idea for you, but it is not a new idea for psychiatrists, who have long recognized that mania is not always a euphoric experience. Although most people associate the idea of mania with feeling good (much too good, in fact), another version of mania is harsh and unpleasant. This version shares the acceleration of the euphoric version, with very rapid thinking, rapid action, and intense, powerful passions. But there is nothing euphoric about it; in fact, it is quite the opposite and thus the term dysphoric. Anger and worry are often very prominent.

Unknown to many people, the negative version is at least as common as the euphoric version. Even less known to most people is that the negative version of mania can occur at the same time as depression symptoms, as you'll see in Chapter 2. This mixed state is known to carry a high risk of suicide. Most mood experts believe that antidepressants given to someone who has bipolar disorder can cause dysphoric mania and mixed states. This phenomenon is one reason why the U.S. Food and Drug Administration (FDA) recommended that everyone given an antidepressant should be screened for bipolar disorder. As you may have heard, the FDA evaluated reports of people who committed suicide shortly after starting an antidepressant. The FDA concluded that at least some of this risk comes from people who look like they have Major Depression (unipolar), but actually have bipolar disorder and receive antidepressants only to end up in an agitated mixed state. The sidebar presents an example of this state, induced by an antidepressant.

The DSM Versus the Mood Spectrum

To understand the importance of a spectrum way of thinking about psychiatric diagnosis, it is important to understand the current, somewhat opposite system of the DSM. The spectrum system sees conditions on a continuum, as in Figure 1.1. The DSM sees conditions as defined by the presence or absence of specific findings. Consider, for example, the DSM criteria for Major Depression, which, believe it or not, I've simplified here:

A. At least one of the following three abnormal moods significantly interfered with the person's life:

1. Abnormal depressed mood

2. Abnormal loss of all interests and pleasure

3. Abnormal irritable mood if person is eighteen or younger

B. At least five of the following symptoms have been present during the same two-week depressed period:

1. Abnormal depressed mood

2. Abnormal loss of all interest and pleasure

3. Appetite or weight disturbance, either:

* Abnormal weight loss (when not dieting) or decrease in appetite

* Abnormal weight gain or increase in appetite

4. Sleep disturbance, either abnormal insomnia or abnormal hypersomnia

5. Activity disturbance, either abnormal agitation or abnormal slowing

6. Abnormal fatigue or loss of energy

7. Abnormal self-reproach or inappropriate guilt

8. Abnormal poor concentration or indecisiveness

9. Abnormal morbid thoughts of death (not just fear of dying) or suicide

C. The symptoms are not due to a mood-in congruent psychosis.

D. There has never been a Manic Episode, a Mixed Episode, or a Hypomanic Episode.

E. The symptoms are not due to physical illness, alcohol, medication, or street drugs.

F. The symptoms are not due to normal bereavement.

As you can see, the DSM criteria are not particularly user-friendly. They look oddly precise and yet arbitrary. For example, according to the DSM criteria for bipolar disorder, a manic episode must last at least seven days. Well, what should be done if some-one's manic episode lasts six and a half days? Is this not bipolar?

However, the DSM actually does serve several useful purposes. For one thing, it is an important tool in research settings. Doctors in Pittsburgh, Pennsylvania, can study Major Depression and compare their results with doctors studying Major Depression in Dallas, Texas, and assume that they are studying roughly the same thing. Clinicians like me (who see patients most of the day, most days a week, as opposed to a researcher, who generally sees a lot fewer patients per week) can read their published research and apply the results to a similar set of patients in their own practice.

In addition, the DSM categories, such as Major Depression and Bipolar Disorder, can be used as a common language by all who understand its diagnostic rules. This enables doctors and...