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Unipolar or Bipolar Depression?

CE / CME

eCase: Identifying Bipolar Disorder in a Currently Depressed Patient

Physician Assistants/Physician Associates: 1.00 AAPA Category 1 CME credit

Nurses: 1.00 Nursing contact hour, including 1.00 hour of pharmacotherapy credit 

Social Workers: 1.00 ASWB ACE CE Credit

Pharmacists: 1.00 contact hour (0.1 CEUs)

Psychologists: 1.00 APA CE Credit

Physicians: Maximum of 1.00 AMA PRA Category 1 Credit™

Released: December 30, 2022

Expiration: December 29, 2023

Denise Vanacore
Denise Vanacore,
CME/CE Information

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According to National Association of Mental Illness, 21% of US adults (52.9 million people or 1 in 5 people) experienced mental illness in 2020.1 Among the mental illnesses are mood disorders, including bipolar disorder. Annually, bipolar disorder affects 2.8%, or approximately 7 million, US adults.1,2

Individuals with bipolar disorder experience recurrent extreme fluctuations in mood—from an ecstatic high (ie, mania, hypomania) to a depressive low. These episodes occur over weeks or months rather than throughout the day. In some patients, a mood episode is “mixed,” meaning that there are both manic/hypomanic and depressive symptoms experienced in the same episode.3

Risk factors for bipolar disorder include family history/genetics, adverse childhood events, trauma, substance abuse, early onset of depression, and history of treatment-resistant depression.4 Regarding family history, those with a first-degree relative with bipolar disorder are approximately 10 times more likely to be diagnosed with bipolar disorder than those without family history of bipolar disorder.5 Furthermore, people with a family history of depression, substance abuse, and/or bipolar disorder are more likely to have more severe illness than those without such a family history.6

Bipolar I and II disorder are differentiated by the presence of mania, as shown in Table 1.7 The presence of at least 1 manic episode in a person’s lifetime is required for a diagnosis of bipolar I disorder. Manic episodes entail abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently goal-directed behavior or energy. To fit the DSM-5-TR criteria for bipolar I disorder, the manic episode must last at least 1 week (or any duration, if hospitalization is necessary). A depressive episode is not necessary for a diagnosis of bipolar I disorder. Bipolar II disorder is not associated with manic episodes. Rather, the patient must have a hypomanic episode lasting at least 4 consecutive days. A major depressive episode is also required for a diagnosis of bipolar II disorder.7

Table 1. Differentiating Bipolar Disorders and Major Depressive Disorder

Mania differs from hypomania in that it causes a major deficit in social or occupational functioning. Common signs and symptoms of a manic or hypomanic episode can be remembered by the mnemonic DIG FAST8:

  • Distractibility
  • Impulsivity, irresponsibility, irritability
  • Grandiosity
  • Flight of ideas and racing thoughts
  • Activity increase/increase in goal-directed behavior (socially, sexually, at work, etc)
  • Sleep deficit (decreased need for sleep)
  • Talkativeness (pressured speech)

The differential diagnosis of bipolar disorder includes several physical health disorders, such as hyperthyroidism, hypothyroidism, Cushing syndrome, autoimmune disorders, and neurosyphilis. In addition, the following psychiatric disorders may be included in the differential or exist as comorbidities to bipolar disorder: anxiety disorder, attention-deficit/hyperactivity disorder, unipolar depression, posttraumatic stress disorder, and seasonal affective disorder.9 Because the majority of patients present with depressive symptoms rather than manic symptoms, bipolar disorder is often misdiagnosed as unipolar major depression.10,11 Consequently, it is estimated that the average time to accurate diagnosis with bipolar disorder is 5-10 years from symptom onset.12,13

The mnemonic WHIPLASHED can help in differentiating unipolar depression from bipolar depression. One point is given if a patient has experienced the any of the following, and a score of 6 or higher may indicate bipolar depression vs unipolar depression14:

  • Worse or wired when receiving antidepressants
  • Hypomanic or manic episodes
  • Irritable, hostile, or mixed features during a period of depression
  • Psychomotor retardation or agitation
  • Loaded family history of affective illness (depression, bipolar)
  • Abrupt onset and/or termination of depressive episodes, brief depressive episodes, or brief burst of increased energy or subthreshold hypomanic symptoms immediately preceding depression onset
  • Seasonal or postpartum pattern of depression
  • Hyperphagia and/or hypersomnia
  • Early age at depression onset
  • Delusions, hallucinations, or psychotic features

Aside from structured interview, validated screening tools are available to help diagnose and rate the severity of bipolar disorder.

Accurate and prompt diagnosis is imperative for treatment outcomes. Bipolar disorder is a lifelong illness requiring both pharmacologic and nonpharmacologic approaches for successful outcomes. There are 3 main goals of treatment: (1) to alleviate or decrease the duration of acute phase illness, (2) to maintain the best level of functioning both socially and occupationally, and (3) to prevent relapse cycles from occurring. by enhancing adherence with medications and other nonpharmacologic treatments. Even with treatment, however, approximately 37% of patients will relapse into a depressive or (hypo)manic episode within 1 year.15

Broadly, pharmacologic agents used in the treatment of bipolar disorder include mood stabilizers, anticonvulsants, antidepressants, and atypical antipsychotics.16 The majority of patients will require polypharmacy for optimal outcomes, and other agents, such as anxiolytics, may be used adjunctly to address residual symptoms. It is important to note, however, that the evidence base for the use of antidepressants in treatment of bipolar disorder is controversial, especially in the case of bipolar I disorder. Antidepressants generally do not have efficacy in manic episodes and may worsen symptoms of agitation and irritability, and in patients with rapid cycling, some studies have identified antidepressant use as a risk factor for more frequent depressive episodes.16,17

Nonpharmacologic strategies with utility in bipolar disorder include psychotherapies (eg, psychoeducation, cognitive behavioral therapy, dialectical behavior therapy), electroconvulsive therapy, and lifestyle modifications.18