A psychiatrist treating a patient for depression must make sure the depression is unipolar, or garden-variety depression, and not bipolar, in which episodes of mania also occur. This is a fictional example of a patient with bipolar disorder:
“Liam” was a 19-year-old college student who was arrested for shoplifting. He had walked out of a department store with a shopping cart full of TV sets. He explained to police in rapid- fire speech that it was okay for him to take the TVs because he was going to make millions of dollars for the department store by writing, directing, and starring in a movie that featured the store. The TVs were for distribution to his future adoring fans, who would watch the movie on TV. He had stayed awake for the past 3 nights writing the script. The “script” that he handed the police had illegible scribbles and symbols written all over it. However, his enthusiasm was so infectious, that the police almost believed him and were half-ready to release him.
Liam’s history was significant for an episode of depression five months prior, shortly after starting an out-of-state college. He had been sad and homesick, and spent most of his time crying in bed. He had stopped going to classes or talking to his friends. He had even considered suicide. He eventually saw a campus doctor, but did not tell him that his mother had taken Lithium for Bipolar Disorder, because this had always been a source of embarrassment for him. He was given an antidepressant. Over the next several days, his depression had improved so much that he stopped his medication and did not show up for his mental health appointments. Now he was feeling “marvelous-never better.”
Liam illustrates the case of a person with classic bipolar disorder- distinct episodes of depression and mania. You may have heard depression referred to as a mood or affective disorder. Mood refers to the way a person feels inside. Affect refers to the expression on a person’s face. Since depression deeply influences mood and facial expression, affective disorder and mood disorder are both appropriate classifications for it.
Depression is not the only condition that affects mood or facial expression. Some scientists believe that mood exists on a spectrum. At one end of the spectrum, or pole is depression. What would be at the opposite pole? Instead of a “down,” depressed mood, there exists an extreme of “up,” elevated, elated mood, called euphoria. These “up” moods are called mania. A person who experiences only depression is said to have Unipolar Depression. People who experience mania suffer from Bipolar Disorder. They have the potential to experience both poles- extreme sadness or euphoria. A normal, healthy, stable mood that is neither depressed nor manic is termed euthymia. (If Goldilocks had Bipolar Disorder, euthymia would be the “just right” mood.) Unfortunately, research has indicated that many people with Bipolar Disorder spend relatively little time euthymic and the majority of the time depressed.
What’s wrong with feeling euphoric? Nothing, if you’re riding a roller coaster or just got a puppy for your birthday. In those situations, it’s normal to feel elated. However, if you’re supposed to be sitting in math class learning long division, breaking out in uncontrollable laughter because you feel euphoric can cause problems for you.
Unfortunately, mania is associated with more than euphoric mood. In many cases, particularly in younger people, a manic mood is not euphoric but extremely irritable and unpleasant. This feeling is often called dysphoria.
Just as depressed people may feel slowed down, apathetic, and unmotivated, manic people feels speeded up and restless. Their thoughts and speech are rapid, their energy and activity levels are increased, and their need for sleep is decreased. It may be difficult to understand them as their speech struggles to keep up with their thoughts. They may quickly change topic in mid-sentence and go off on a tangent-indicating tangential thinking. They are often grandiose-they have an inflated belief in their skills and accomplishments. Unfortunately, they tend to act impulsively with risky behaviors, heedless of the consequences. A manic adult may spend excessive money, have unprotected sex with multiple partners, or race a car well above the speed limit. A person with irritable, dysphoric mania is at risk for arguments and physical fights. A person with severe mania may develop disorganized thinking and become delusional and psychotic. They may hear voices and/or falsely think that there is a special plan in place for them, whether arranged by G-d, space aliens, or the FBI.
It is very important to distinguish unipolar from bipolar depression. People with bipolar depression can become manic if they take antidepressants. They must take a different type of medicine, mood stabilizers (lithium, certain anti-seizure medications, and/or neuroleptics) to treat mania. Antidepressants may be considered later if they still have depression despite their mania having resolved on a good dose of a mood stabilizer. A patient presenting to a psychiatrist with depression will be carefully screened for bipolar disorder to ensure the right type of medication is given.