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135: Bipolar and Depression

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Bipolar and Related Disorders

Chronic mood disorder with episodes of mania/hypomania and depression.
Onset typically late teens–20s. Equal in men/women. Strong genetic predisposition.

Clinical Presentation

Bipolar I Disorder

  • At least 1 manic episode (≥1 week, elevated/irritable mood + ↑ energy, often with decreased need for sleep, pressured speech, grandiosity, impulsivity).
  • May have depressive episodes, but not required for diagnosis.
  • Severe impairment, may include psychosis or require hospitalization.

Bipolar II Disorder

  • At least 1 hypomanic episode (≥4 days, same manic symptoms but less severe, no marked impairment, no psychosis).
  • At least 1 major depressive episode required.
  • More often misdiagnosed as recurrent depression.

Cyclothymic Disorder

  • ≥2 years of fluctuating hypomanic and depressive symptoms not meeting full criteria for hypomania or major depression.
  • Considered a “milder, chronic” bipolar spectrum disorder.

Hallmark exam clues

  • Decreased need for sleep (not just insomnia).
  • Pressured speech and flight of ideas.
  • Risky behaviors (spending sprees, hypersexuality, substance use).
  • Misdiagnosis as MDD is common — always ask about past mania/hypomania.

Labs, Studies, and Physical Exam Findings

  • Primarily a clinical diagnosis.
  • Rule out secondary causes: thyroid dysfunction, substance use, CNS lesions, medications (e.g., steroids, stimulants).
  • Use screening tools (e.g., Mood Disorder Questionnaire).

Treatment

First-line (mood stabilizers):

  • Lithium: gold standard for mania and maintenance (requires monitoring for toxicity, renal function, thyroid).
  • Valproic acid: effective for mania, mixed episodes.
  • Carbamazepine: alternative mood stabilizer.
  • Lamotrigine: more effective for bipolar depression and maintenance, not acute mania.

Adjunctive / Antipsychotics:

  • Atypical antipsychotics (quetiapine, olanzapine, risperidone, lurasidone, etc.) useful in acute mania and bipolar depression.

Antidepressants:

  • Avoid monotherapy (can precipitate mania).
  • If used, must be combined with a mood stabilizer.

Non-pharmacologic:

  • Psychotherapy (CBT, family-focused therapy).
  • Lifestyle: regular sleep, avoid substances.

Key Differentiators

Bipolar I vs. Bipolar II

  • Bipolar I: At least 1 manic episode (≥1 week, severe, may require hospitalization, may include psychosis).
  • Bipolar II: At least 1 hypomanic episode (≥4 days, no marked impairment, no psychosis) AND ≥1 major depressive episode.

Bipolar II vs. Cyclothymic Disorder

  • Bipolar II: Requires at least one full major depressive episode plus hypomania.
  • Cyclothymic Disorder: ≥2 years of fluctuating hypomanic and depressive symptoms, but never meeting full criteria for hypomania or major depression.

Bipolar vs. Major Depressive Disorder (MDD)

  • Bipolar: Requires history of mania or hypomania.
  • MDD: Depression only, no elevated mood episodes.

Bipolar vs. Borderline Personality Disorder

  • Bipolar: Episodic mood episodes lasting days to weeks.
  • Borderline: Moment-to-moment affective instability, often triggered by interpersonal stressors.

Depressive Disorders

Major Depressive Disorder (MDD)

  • Lifetime prevalence ~15–20%
  • More common in women
  • Average onset: mid-20s

Clinical Presentation

  • At least 2 weeks of depressed mood or anhedonia (loss of pleasure/interest).
  • Must include ≥5 total symptoms causing functional impairment.
  • Common features (SIGECAPS):
    • Sleep disturbance (insomnia or hypersomnia)
    • Interest loss (anhedonia)
    • Guilt or worthlessness
    • Energy loss/fatigue
    • Concentration difficulties
    • Appetite/weight changes
    • Psychomotor agitation or slowing
    • Suicidal thoughts or recurrent thoughts of death

Labs, Studies, and Physical Exam Findings

  • Diagnosis is clinical.
  • Exclude medical causes (e.g., hypothyroidism, substance/medication effects).
  • Screening tools: PHQ-9 (Patient Health Questionnaire) and Beck Depression Inventory (symptom rating scales).

Treatment

  • First-line: SSRIs (fluoxetine, sertraline, escitalopram).
  • Alternatives: SNRIs (venlafaxine, duloxetine), bupropion, mirtazapine, TCAs.
  • Severe/refractory cases: Electroconvulsive therapy (ECT) — safe in pregnancy, elderly, or catatonia.
  • Non-pharmacologic: Cognitive Behavioral Therapy (CBT), Interpersonal Therapy (IPT).
  • Lifestyle: Exercise, sleep hygiene, social connection.

Key Differentiator with Bipolar Disorder

  • MDD: Only depressive episodes, no history of mania or hypomania.
  • Bipolar Disorder: At least one episode of mania or hypomania (even if depression is the presenting complaint).

Persistent Depressive Disorder (Dysthymia)

  • Lifetime prevalence ~3–6%
  • More common in women
  • Onset often in adolescence or early adulthood
  • Course is chronic and insidious

Clinical Presentation

  • Depressed mood for ≥2 years (≥1 year in children/adolescents).
  • Symptoms present most of the day, more days than not.
  • During the 2-year period, never without symptoms for >2 months.
  • Must include at least 2 or more:
    • Poor appetite or overeating
    • Insomnia or hypersomnia
    • Low energy or fatigue
    • Low self-esteem
    • Poor concentration or difficulty making decisions
    • Feelings of hopelessness
  • Often described as being a “gloomy, always down” person.

Labs, Studies, and Physical Exam Findings

  • Clinical diagnosis.
  • Rule out medical causes (thyroid disease, chronic illness, substance/medication).
  • Screening tools: Same as MDD (PHQ-9, Beck Depression Inventory) but symptoms are less severe and more chronic.

Treatment

  • First-line: SSRIs (e.g., fluoxetine, sertraline, escitalopram).
  • Alternatives: SNRIs, bupropion, mirtazapine.
  • Psychotherapy: Particularly effective (CBT, interpersonal therapy).
  • Combination of meds + therapy often most effective given chronic nature.

Key Differentiator with MDD

  • MDD: Episodic, ≥2 weeks, often more severe.
  • Dysthymia: Chronic low-grade depression, ≥2 years, often milder but persistent.

Premenstrual Dysphoric Disorder (PMDD)

  • Affects ~3–8% of menstruating women
  • Onset: late teens to 20s, symptoms recur with menstrual cycles
  • Strong association with functional impairment (work, school, relationships)

Clinical Presentation

  • Symptoms occur during the luteal phase (1–2 weeks before menses) and resolve with onset of menstruation.
  • Must have ≥5 symptoms with at least one from the affective category:
    • Mood swings, irritability, or anger
    • Depressed mood or hopelessness
    • Anxiety or tension
  • Additional symptoms:
    • Decreased interest in usual activities
    • Difficulty concentrating
    • Lethargy, fatigue
    • Appetite changes, food cravings
    • Sleep disturbance (insomnia/hypersomnia)
    • Physical symptoms (breast tenderness, bloating, joint/muscle pain)
  • Symptoms must be severe enough to interfere with daily functioning.

Labs, Studies, and Physical Exam Findings

  • Diagnosis is clinical; prospective daily ratings of symptoms over at least 2 cycles recommended.
  • Must rule out other mood disorders (e.g., MDD, dysthymia).

Treatment

  • First-line: SSRIs (fluoxetine, sertraline, paroxetine) — effective both continuously or luteal-phase dosing.
  • Alternative pharmacologic: Combined oral contraceptives (especially drospirenone-containing formulations).
  • Severe/refractory: GnRH agonists or oophorectomy (rare).
  • Non-pharmacologic: Regular exercise, stress reduction, CBT, adequate sleep.

Key Differentiator

  • PMDD: Cyclic pattern tied to luteal phase, resolves with menstruation.
  • MDD/Persistent Depressive Disorder: Symptoms are persistent, not cycle-related.

Suicidal and Homicidal Behaviors

  • Suicide is the 10th leading cause of death in the U.S.
  • Highest risk: older white men, but attempts more common in women.
  • Commonly associated with: depression, bipolar disorder, substance use, schizophrenia, chronic medical illness.

Clinical Presentation

Warning signs:

  • Expressing hopelessness or worthlessness
  • Talking about wanting to die or kill oneself
  • Increased substance use
  • Withdrawal from friends/family
  • Giving away possessions, finalizing affairs

Risk factors (mnemonic SAD PERSONS):

  • Sex (male)
  • Age (elderly, teens)
  • Depression
  • Previous attempt
  • Ethanol/drug use
  • Rational thinking loss (psychosis)
  • Social support lacking
  • Organized plan
  • No spouse
  • Sickness (chronic illness)

Labs, Studies, and Physical Exam Findings

  • No lab test; diagnosis is clinical and risk-assessment based.
  • Must directly ask about suicidal thoughts, plan, and intent.
  • For homicidal ideation: always assess access to weapons and specific plans.

Treatment / Management

  • Suicidal patient with plan/intent:
    • Immediate psychiatric evaluation.
    • Hospitalization (involuntary if necessary).
    • Ensure safety — remove lethal means.
  • Suicidal ideation without plan/intent:
    • Outpatient referral, safety planning, close follow-up.
  • Pharmacologic: Treat underlying psychiatric disorder (SSRIs for depression, mood stabilizers for bipolar).
  • Crisis intervention: Suicide hotlines, CBT, family involvement.
  • Homicidal risk:
    • Duty to warn/protect (Tarasoff rule) — must breach confidentiality if there is a credible threat to others.

Tarasoff Rule (Duty to Warn/Protect)

  • Origin: From a 1976 California Supreme Court case (Tarasoff v. Regents of the University of California).
  • Core principle:
    • If a patient makes a credible threat of serious violence against an identifiable person, the provider has a duty to warn/protect that potential victim.
  • This overrides patient confidentiality.

For PANCE:

  • If a patient says: “I’m going to kill my neighbor tomorrow with my gun” → You must act.
  • Appropriate actions include:
    • Notifying law enforcement
    • Warning the intended victim
    • Taking reasonable steps to protect (e.g., hospitalization)

Key Differentiators

  • Suicide: men complete, women attempt.
  • Most important risk factor: previous suicide attempt.
  • In the ER setting: always ask directly — asking does not increase risk, it improves safety.
  • If homicidal with specific intent/plan → involuntary hospitalization and notify authorities.

Recap Key Differentiators: Mood Disorders & Suicide Risk

Bipolar I vs. Bipolar II

  • Bipolar I = mania (≥1 week, severe, may need hospitalization/psychosis).
  • Bipolar II = hypomania (≥4 days, no psychosis, no hospitalization) + major depression.
    Test Alert: A patient with depression + any history of mania/hypomania → this is Bipolar, not “treatment-resistant depression.”

Bipolar II vs. Cyclothymic Disorder

  • Bipolar II: Requires a major depressive episode.
  • Cyclothymic: ≥2 years of subthreshold mood swings but never full mania/hypomania or major depression.
    Test Alert: A patient with “mood swings for 3 years but never full mania or depression” = Cyclothymia.

MDD vs. Bipolar Disorder

  • MDD = depression only, no history of mania/hypomania.
  • Bipolar = requires history of mania/hypomania.
    Test Alert: Depression treated with SSRI alone → patient develops mania → you missed Bipolar II.

MDD vs. Persistent Depressive Disorder (Dysthymia)

  • MDD = episodic, ≥2 weeks, often more severe.
  • Dysthymia = chronic, ≥2 years, milder, never without symptoms >2 months.
    Test Alert: Someone “always gloomy” for 3 years with low energy, poor concentration, low self-esteem = Persistent Depressive Disorder.

PMDD vs. MDD/Dysthymia

  • PMDD = cyclic, tied to luteal phase, resolves with menses.
  • MDD/Dysthymia = persistent, not cycle-related.
    Test Alert: Symptoms that disappear once menstruation begins = PMDD, not depression.

Suicidal vs. Homicidal Risk (Ethics)

  • Suicide risk: duty to protect the patient (hospitalization, safety plan).
  • Homicidal risk with specific victim/plan: duty to warn/protect others (Tarasoff Rule).
    Test Alert: A patient says “I’m going to shoot my coworker tomorrow” → correct answer = warn the victim/law enforcement, not just “increase therapy visits.”

How it shows up on the PANCE:

  • You’ll often get vignettes with subtle differences in duration, severity, or triggers.
  • The exam wants to see if you catch the timeline (≥2 weeks vs. ≥2 years vs. cyclic) and the presence/absence of mania/hypomania.
  • For suicide/homicide: questions test whether you know when to breach confidentiality.