Thursday, 3 December 2009
Depression Quotes: Collection of depression quotes
Depression Quotes: Collection of depression quotes: "Depression is like a drug that turns you into a person opposite of yourself. Whatever you think while you are on depression is false. Depression makes you believe that everyone hates you and you hate yourself and also that things are really bad.this is not TRUE. Understand that depression exists in the mind and it takes over a person, just think how some people are alcoholics
or drug addicts. The same things happen to them just start praying and also forgive yourself and your enemies, you will feel alot better trust me. Then just tell people you know and people that like and love you. You tell them you have a problem and explain to them then go get help. Help is all around you. Tell your family, tell your friends parents ETC, remember that whatever you think they belive its not probably true. They dont hate you trust me in your mind you hate verything and everyone including yourself all that is not true.go to people you can trust, go to church and talk to a priest, you got to communicate, just remember, it took you awhile to GET depressed, its gonna take time to get undepressed, its just like a addiction, its gonna take time.
(Sent in by Dylan Jan 12, 2006 )"
Depression Quotes: Collection of depression quotes
Depression Quotes: Collection of depression quotes: "Depression to me is like a deep dark pit that once you have reached bottom there is no escape.
At first began to feel yourself slding into the shadows and then complete isolation from life. Things begain to lose their color. yellows of the sunshine, and blues of the sky fade to a grey and bleak shadow that seems to ovewhelm me. I can no longer see or hear things that are pleasing to me anymore. Dark thoughts of fear and failure dwell within my mind almost constantly. I feel numb to the world and people around me. I want to be left alone because it takes so much work to hide the true pain and sadness I am feeling. The guilt for not being able to handle simple conversations. It is so hard and exhausting to pretend with people that I am ok when in fact I have spiraled downward into what I call THE PIT. It is deep, dark, lonely and inescapable for me sometimes.
(Sent in by Mercedes Jan 18, 2006 )"
At first began to feel yourself slding into the shadows and then complete isolation from life. Things begain to lose their color. yellows of the sunshine, and blues of the sky fade to a grey and bleak shadow that seems to ovewhelm me. I can no longer see or hear things that are pleasing to me anymore. Dark thoughts of fear and failure dwell within my mind almost constantly. I feel numb to the world and people around me. I want to be left alone because it takes so much work to hide the true pain and sadness I am feeling. The guilt for not being able to handle simple conversations. It is so hard and exhausting to pretend with people that I am ok when in fact I have spiraled downward into what I call THE PIT. It is deep, dark, lonely and inescapable for me sometimes.
(Sent in by Mercedes Jan 18, 2006 )"
Depression Quotes: Collection of depression quotes
Depression Quotes: Collection of depression quotes: "You cry... you feel sad... you get 'help'... but its still there... only now you hide it... you want everyone to believe it is ok... but its not, i'm not ok- its a rollercoaster of emotions, you slowly start to feel better and then all of a sudden you crash again... then it starts all over.
(Sent in by Mallisa March 6, 2006 )"
(Sent in by Mallisa March 6, 2006 )"
Do I Have Depression?
Do I Have Depression?: "Do I Have Depression?
If you or someone you love is struggling with depression, you've probably got questions—lots of them. We’ve got answers. At this stage, although your energy level may be low, gathering knowledge is crucial. Below you’ll find articles written by individuals who have been where you are. They’ll help you figure out whether you're dealing with clinical depression or just sadness. Our experts will also help you decide what steps you should take to feel better."
If you or someone you love is struggling with depression, you've probably got questions—lots of them. We’ve got answers. At this stage, although your energy level may be low, gathering knowledge is crucial. Below you’ll find articles written by individuals who have been where you are. They’ll help you figure out whether you're dealing with clinical depression or just sadness. Our experts will also help you decide what steps you should take to feel better."
Antidepressants That Aren't Antidepressants
Antidepressants That Aren't Antidepressants: "ntroduction
Although this page will repeat some ideas you'll find elsewhere on this website, they seemed worth presenting together. After all, these may be the most important concepts on this website. Consider the following logic:
1.
Depression is the most common symptom in bipolar disorder.
2.
Antidepressant medications (Prozac, Paxil, Celexa, Effexor, etc.) can be very effective against depression.
3.
Result: antidepressants are commonly used in bipolar disorder.
That's where we are at the present time, in practice. But here is more logic to consider.
1.
Antidepressants can make bipolar disorder worse (some of these are controversial; here are the data on that).
*
They can cause hypomania where there was none.
*
They can induce cycling, or make it worse.
*
They may keep a person from becoming truly stable.
*
And they might, just might, cause some long-term harm, perhaps even irreversible harm.
2.
Therefore: antidepressants should be avoided, as much as possible, in bipolar disorder treatment.
(This statement in particular is controversial).
Now, let's combine these two bits of logic:
1.
Some antidepressant tool is commonly necessary in bipolar disorder.
2.
Yet true 'antidepressants' should be avoided, if possible, in bipolar treatment.
3.
Therefore, one should maximize use of all other antidepressant approaches before using typical 'antidepressants'.
(Again, this is my personal conclusion, not an expert opinion or mandate).
Fortunately, there are at least nine such approaches to consider. These approaches are not associated with increasing cycling, long-term destabilizing, or the concerns about possible long-term harm which have been raised about typical antidepressants. They all have other risks, but so do any treatments you might consider. For any approach you take, you will always be balancing risks versus possible benefits.
Before we turn to that list of nine options, however, there is an even more important principle to consider -- because it might make those eight options unnecessary.
First, Stop The Cycling
For many people, their depressions are not constant. Instead, they 'cycle' into depression, and out again -- although the respite is often brief. However, if it is clear that your moods do indeed cycle, then the first thing to do is stop the cycling. A lot of people will find that their mood smoothes out at an acceptable level.
I hope you see what this means: if you stop the cycling, you might stop having depressions entirely -- so you wouldn't need an antidepressant, of any kind. And this makes bipolar treatment a lot simpler, because you can stop the cycling with 'any old mood stabilizer', not just the ones with antidepressant effects. This allows you to choose from the entire menu, not just the ones (shown below) which have antidepressant effects. That's good, because sometimes you'll want that entire menu available, to pick the one with the least troublesome side effects for you.
After that step is complete, when you are no longer having cycling, then, if you are still depressed, you should consider options from the list below. Then, when you have considered these options and perhaps used one or several, then you may be one of those people who really need to add an antidepressant, with caution, to your mood stabilizers -- in my opinion. (There are exceptions, including especially people who have been on an antidepressant for years and doing well, with no cycling. These people may do best to stay on their antidepressant, although even that is controversial: see Controversy 3 on this page.)
(A note for people with pleasurable hypomania -- which may be less than half of those with Bipolar II: you may be disappointed to see that the 'stable place' is not up there at the top of where you used to sometimes find yourself. Surprise -- those higher places were 'hypomania', on your personal scale. Yet most folks like you prefer 'stable' to cycling, which almost inevitably includes phases of depression that are longer than the ups, more disabling, and ultimately just not worth going through for those brief higher phases.)
(A note for people with constant depression and cycling: you too may be disappointed to see that your mood levels out at a familiar place, namely that constant background level of depression. Nevertheless, the same series of steps seems to me to apply: first try to stop the cycling, because if you add an antidepressant to go after the background depression, you'll commonly make the cycling worse or at least less stop-able; whereas if you stop the cycling first, some of the approaches below may boost your whole 'baseline' depression up towards where you see everyone else apparently living (some really are living there, some are faking it, as you know)).
Nine Antidepressants Options That Are Not 'Antidepressants'
(Each of the 'pill' options in this table has its own page of additional information; see Mood Stabilizers table of all the options.)
No Pills
Risk or Problems
'Natural' pills
Risk or Problems
Mood Stabilizers With
Antidepressant Effects
Possible Risks (not all get them)
Exercise
Possible Injury
omega-3 fatty acids
(fish oil)
Lots of pills
Lamictal (lamotrigine)
Severe skin problems 1/3000
Cognitive-Behavioral Therapy
Cost, Time; Finding a Good Therapist
optimize thyroid
Blood tests, hyperthyroidism
Seroquel (quetiapine)
Weight gain, diabetes
Light manipulations
(dark therapy, light box, dawn simulator)
Cost; Routines Are Limiting
lithium
blood tests, hypothyroidism, long-term kidney risk
Zyprexa (olanzapine)
Weight gain, diabetes
Okay, I admit, dark therapy doesn't quite belong on this list, as it does not have direct antidepressant effects, only mood stabilizing effects, but it's such a cool idea, I think everybody needs to know about it -- because some limited version of it is within reach for almost everyone. If you're interested in how mood is affected by light, see my essay on Bipolar Disorder: Light and Darkness. You'll see how the biological clock is affected very directly by both (and find interesting links about how the clock works and how lithium affects it; and about why blue light appears to be more important than any other wavelength when it comes to mood effects).
Similarly, optimizing thyroid -- getting near the hyperthyroid side of normal, or at least making sure you're not near the hypothyroid side of normal -- is not directly antidepressant but may allow whatever antidepressant things you're doing to work better. It too is on the list because I think it is so nice to be able to offer options which carry zero, or near zero risk (as long as you don't end up becoming hyperthyroid, which should be relatively easy to avoid). For more, see Thyroid and Bipolar disorders, including the references on which this approach is based and a reminder that this is not even an experimental approach, just a working guess.
Finally, lithium is listed in the 'natural' column. Okay, that's a stretch, perhaps, as it is made by pharmaceutical companies and must be handled just like other medications, with caution (possibly excepting lithium orotate, a very long story in itself; it may actually work, theoretically, but safety remains to be demonstrated after one study suggested risk) . But it does come from the earth, after all...
(A brief word on some medications that other psychiatrists might have included in this table: valproate (Depakote) and risperidone (Risperdal); perhaps aripiprazole; and maybe even ziprasidone (Geodon). I have not included risperidone and valproate in the table above because: a) I find risperidone actually has too much antidepressant-like action and may induce a subtle agitation/insomnia/cycling that is hard to manage, because one will always be wondering if it is coming from the patient or from the risperidone; and b) although Depakote has a recent pilot studyDavis demonstrating an antidepressant effect, as well as a small study of less direct designWinsberg, it has not impressed me with its antidepressant effects as have those three listed.)
Conclusion: Why is there such reliance on antidepressants?
I hope this essay may have led you to wonder: with all these options to manage depression in bipolar disorder, and with the risks antidepressants pose (or may pose, depending on how you interpret the current controversies), why does anyone persist in using antidepressants in bipolar patients -- at all?
Obviously I wonder that myself. As I listen to doctors talk about this, it seems there are several factors:
*
Habit: we've been using them for a long time, and they do help quite a few people (even many people with bipolar disorder -- initially).
*
A short-term view of treatment, focusing on the symptom du jour, instead of the long-term goal of stopping cycling as a means of addressing repeated episodes of depression. It's easy to get drawn into treating today's symptom, when you're sitting with a patient who is really depressed, who wants an antidepressant, and who has not learned all you have learned about antidepressants' possible risks.
*
A different interpretation of the available data on risk. You might hope this would be the main explanation. However, I fear that many doctors are unaware of the data we have on the risk controversies.
You may have seen Dr. Ghaemi's data about use of antidepressants in patients with bipolar diagnoses:
To me this suggests that the more one learns about bipolar disorder, from treating patients long-term, the less one uses antidepressants. The good news is that we have at least nine other options to consider! Go read more about them, starting with the table on the the mood stabilizer page."
Although this page will repeat some ideas you'll find elsewhere on this website, they seemed worth presenting together. After all, these may be the most important concepts on this website. Consider the following logic:
1.
Depression is the most common symptom in bipolar disorder.
2.
Antidepressant medications (Prozac, Paxil, Celexa, Effexor, etc.) can be very effective against depression.
3.
Result: antidepressants are commonly used in bipolar disorder.
That's where we are at the present time, in practice. But here is more logic to consider.
1.
Antidepressants can make bipolar disorder worse (some of these are controversial; here are the data on that).
*
They can cause hypomania where there was none.
*
They can induce cycling, or make it worse.
*
They may keep a person from becoming truly stable.
*
And they might, just might, cause some long-term harm, perhaps even irreversible harm.
2.
Therefore: antidepressants should be avoided, as much as possible, in bipolar disorder treatment.
(This statement in particular is controversial).
Now, let's combine these two bits of logic:
1.
Some antidepressant tool is commonly necessary in bipolar disorder.
2.
Yet true 'antidepressants' should be avoided, if possible, in bipolar treatment.
3.
Therefore, one should maximize use of all other antidepressant approaches before using typical 'antidepressants'.
(Again, this is my personal conclusion, not an expert opinion or mandate).
Fortunately, there are at least nine such approaches to consider. These approaches are not associated with increasing cycling, long-term destabilizing, or the concerns about possible long-term harm which have been raised about typical antidepressants. They all have other risks, but so do any treatments you might consider. For any approach you take, you will always be balancing risks versus possible benefits.
Before we turn to that list of nine options, however, there is an even more important principle to consider -- because it might make those eight options unnecessary.
First, Stop The Cycling
For many people, their depressions are not constant. Instead, they 'cycle' into depression, and out again -- although the respite is often brief. However, if it is clear that your moods do indeed cycle, then the first thing to do is stop the cycling. A lot of people will find that their mood smoothes out at an acceptable level.
I hope you see what this means: if you stop the cycling, you might stop having depressions entirely -- so you wouldn't need an antidepressant, of any kind. And this makes bipolar treatment a lot simpler, because you can stop the cycling with 'any old mood stabilizer', not just the ones with antidepressant effects. This allows you to choose from the entire menu, not just the ones (shown below) which have antidepressant effects. That's good, because sometimes you'll want that entire menu available, to pick the one with the least troublesome side effects for you.
After that step is complete, when you are no longer having cycling, then, if you are still depressed, you should consider options from the list below. Then, when you have considered these options and perhaps used one or several, then you may be one of those people who really need to add an antidepressant, with caution, to your mood stabilizers -- in my opinion. (There are exceptions, including especially people who have been on an antidepressant for years and doing well, with no cycling. These people may do best to stay on their antidepressant, although even that is controversial: see Controversy 3 on this page.)
(A note for people with pleasurable hypomania -- which may be less than half of those with Bipolar II: you may be disappointed to see that the 'stable place' is not up there at the top of where you used to sometimes find yourself. Surprise -- those higher places were 'hypomania', on your personal scale. Yet most folks like you prefer 'stable' to cycling, which almost inevitably includes phases of depression that are longer than the ups, more disabling, and ultimately just not worth going through for those brief higher phases.)
(A note for people with constant depression and cycling: you too may be disappointed to see that your mood levels out at a familiar place, namely that constant background level of depression. Nevertheless, the same series of steps seems to me to apply: first try to stop the cycling, because if you add an antidepressant to go after the background depression, you'll commonly make the cycling worse or at least less stop-able; whereas if you stop the cycling first, some of the approaches below may boost your whole 'baseline' depression up towards where you see everyone else apparently living (some really are living there, some are faking it, as you know)).
Nine Antidepressants Options That Are Not 'Antidepressants'
(Each of the 'pill' options in this table has its own page of additional information; see Mood Stabilizers table of all the options.)
No Pills
Risk or Problems
'Natural' pills
Risk or Problems
Mood Stabilizers With
Antidepressant Effects
Possible Risks (not all get them)
Exercise
Possible Injury
omega-3 fatty acids
(fish oil)
Lots of pills
Lamictal (lamotrigine)
Severe skin problems 1/3000
Cognitive-Behavioral Therapy
Cost, Time; Finding a Good Therapist
optimize thyroid
Blood tests, hyperthyroidism
Seroquel (quetiapine)
Weight gain, diabetes
Light manipulations
(dark therapy, light box, dawn simulator)
Cost; Routines Are Limiting
lithium
blood tests, hypothyroidism, long-term kidney risk
Zyprexa (olanzapine)
Weight gain, diabetes
Okay, I admit, dark therapy doesn't quite belong on this list, as it does not have direct antidepressant effects, only mood stabilizing effects, but it's such a cool idea, I think everybody needs to know about it -- because some limited version of it is within reach for almost everyone. If you're interested in how mood is affected by light, see my essay on Bipolar Disorder: Light and Darkness. You'll see how the biological clock is affected very directly by both (and find interesting links about how the clock works and how lithium affects it; and about why blue light appears to be more important than any other wavelength when it comes to mood effects).
Similarly, optimizing thyroid -- getting near the hyperthyroid side of normal, or at least making sure you're not near the hypothyroid side of normal -- is not directly antidepressant but may allow whatever antidepressant things you're doing to work better. It too is on the list because I think it is so nice to be able to offer options which carry zero, or near zero risk (as long as you don't end up becoming hyperthyroid, which should be relatively easy to avoid). For more, see Thyroid and Bipolar disorders, including the references on which this approach is based and a reminder that this is not even an experimental approach, just a working guess.
Finally, lithium is listed in the 'natural' column. Okay, that's a stretch, perhaps, as it is made by pharmaceutical companies and must be handled just like other medications, with caution (possibly excepting lithium orotate, a very long story in itself; it may actually work, theoretically, but safety remains to be demonstrated after one study suggested risk) . But it does come from the earth, after all...
(A brief word on some medications that other psychiatrists might have included in this table: valproate (Depakote) and risperidone (Risperdal); perhaps aripiprazole; and maybe even ziprasidone (Geodon). I have not included risperidone and valproate in the table above because: a) I find risperidone actually has too much antidepressant-like action and may induce a subtle agitation/insomnia/cycling that is hard to manage, because one will always be wondering if it is coming from the patient or from the risperidone; and b) although Depakote has a recent pilot studyDavis demonstrating an antidepressant effect, as well as a small study of less direct designWinsberg, it has not impressed me with its antidepressant effects as have those three listed.)
Conclusion: Why is there such reliance on antidepressants?
I hope this essay may have led you to wonder: with all these options to manage depression in bipolar disorder, and with the risks antidepressants pose (or may pose, depending on how you interpret the current controversies), why does anyone persist in using antidepressants in bipolar patients -- at all?
Obviously I wonder that myself. As I listen to doctors talk about this, it seems there are several factors:
*
Habit: we've been using them for a long time, and they do help quite a few people (even many people with bipolar disorder -- initially).
*
A short-term view of treatment, focusing on the symptom du jour, instead of the long-term goal of stopping cycling as a means of addressing repeated episodes of depression. It's easy to get drawn into treating today's symptom, when you're sitting with a patient who is really depressed, who wants an antidepressant, and who has not learned all you have learned about antidepressants' possible risks.
*
A different interpretation of the available data on risk. You might hope this would be the main explanation. However, I fear that many doctors are unaware of the data we have on the risk controversies.
You may have seen Dr. Ghaemi's data about use of antidepressants in patients with bipolar diagnoses:
To me this suggests that the more one learns about bipolar disorder, from treating patients long-term, the less one uses antidepressants. The good news is that we have at least nine other options to consider! Go read more about them, starting with the table on the the mood stabilizer page."
I am a depressed agoraphobic - Agoraphobia - MedHelp
I am a depressed agoraphobic - Agoraphobia - MedHelp: "I am 20 years old and for the last 2 years I have been a concealed depressant. I have told no one, in or out of my familyBirth control and family planning
Choosing a primary care provider
Ewing’s sarcoma
Family troubles - resources, of my dailyDaily combo
Daily multiple for men 50+
Daily multiple for women
Daily multiple for women 50+
Daily multiple vitamins
Daily vite
Daily-vite men's formula
Daily-vite weight control thoughts of suicideSuicide and suicidal behavior nor of my intentions of suicideSuicide and suicidal behavior. I am rather good at not letting anyone know how I feel and pretending that I am completely fine. Since my freshman year of highschool I have been scared of social events and imbarassing or making myself look stupid in front of people. Rather than looking foolish in front of others I decided to hide myself away from the world and become my own best friend. I spent the entirety of my highschool days playing video games online in my parents basement, which made my only friends those in the online world. I went into college hoping for a better life but found myself seemingly unlikeable and undesirable to be around. I don't have any friends now and I can't remember the last time I left the house on a Friday night. I have spent the vast majority of my time concealed inside my own house playing video games, only now I have given up on the online friendships as well. I realize that there are people I could probably call and with some sympathy they would probably hang out with me. Afraid of when I am with people however I will often find myself thinking of not looking stupid and awkward, often leading me to panicPanic disorder
Panic disorder with agoraphobia and unable to carry a normalNormal saline flush conversation thus in term looking even more stupid. I have come up with about a half dozen ways to kill myself and nearly attempted over a dozen times, most of an unconvincing nature of success. I am absolutely positive I am going to kill myself but in fear of hurting my parents in a delicate time of their own I wait anxiously. I don't want to hear any sob stories about how their is so much to live for and that it is stupid to kill myself. I'm sorry I don't believe there is any possible way our souls are transported through magical gateways to heaven or hell set by rules from long told fairy tales. I have found myself in fear of life, begging for a soon coming quick and painless death. I do not fear death as I believe that my energy simply will become part of another energy. In a planet that is being overrun and consumed by my species, I don't think the stopping of consumption and the giving of my energy to another is stupid. The world would probably be a better place if a few hundred million of us were just dropped off of it. I am tired of people and I am tired most of my incompetence."
Choosing a primary care provider
Ewing’s sarcoma
Family troubles - resources, of my dailyDaily combo
Daily multiple for men 50+
Daily multiple for women
Daily multiple for women 50+
Daily multiple vitamins
Daily vite
Daily-vite men's formula
Daily-vite weight control thoughts of suicideSuicide and suicidal behavior nor of my intentions of suicideSuicide and suicidal behavior. I am rather good at not letting anyone know how I feel and pretending that I am completely fine. Since my freshman year of highschool I have been scared of social events and imbarassing or making myself look stupid in front of people. Rather than looking foolish in front of others I decided to hide myself away from the world and become my own best friend. I spent the entirety of my highschool days playing video games online in my parents basement, which made my only friends those in the online world. I went into college hoping for a better life but found myself seemingly unlikeable and undesirable to be around. I don't have any friends now and I can't remember the last time I left the house on a Friday night. I have spent the vast majority of my time concealed inside my own house playing video games, only now I have given up on the online friendships as well. I realize that there are people I could probably call and with some sympathy they would probably hang out with me. Afraid of when I am with people however I will often find myself thinking of not looking stupid and awkward, often leading me to panicPanic disorder
Panic disorder with agoraphobia and unable to carry a normalNormal saline flush conversation thus in term looking even more stupid. I have come up with about a half dozen ways to kill myself and nearly attempted over a dozen times, most of an unconvincing nature of success. I am absolutely positive I am going to kill myself but in fear of hurting my parents in a delicate time of their own I wait anxiously. I don't want to hear any sob stories about how their is so much to live for and that it is stupid to kill myself. I'm sorry I don't believe there is any possible way our souls are transported through magical gateways to heaven or hell set by rules from long told fairy tales. I have found myself in fear of life, begging for a soon coming quick and painless death. I do not fear death as I believe that my energy simply will become part of another energy. In a planet that is being overrun and consumed by my species, I don't think the stopping of consumption and the giving of my energy to another is stupid. The world would probably be a better place if a few hundred million of us were just dropped off of it. I am tired of people and I am tired most of my incompetence."
Hard Depression, Soft Bipolar
Hard Depression, Soft Bipolar: "Jim Phelps MD is an Oregon psychiatrist in private practice The name of his new book is 'Why Am I Still Depressed?: Recognizing and Managing the Ups and Downs of Bipolar II and Soft Bipolar Disorder.' A better title might have been, 'Screw the DSM: Let’s Discuss What’s Really Going On.'
'In the DSM mode of thinking,' Dr Phelps tells us, 'making an accurate diagnosis requires determining whether the patient with depression symptoms is unipolar or bipolar, whereas in the Mood Spectrum approach, we clinicians don’t ask what might be the most accurate label for you. Instead, we ask where might your symptoms lie on the Mood Spectrum. … Instead of saying yes or no as to whether you might have bipolar disorder [we] try to determine how much bipolarity you have.'
The diagnostic threshold for bipolar II is hypomania, but here’s the catch: Hypomania is often barely discernible, especially in a population that may spend 50 days depressed for every one day hypomanic. A walk on the wild side for some may be using real butter on their toast.
Dr Phelps cites Hagop Akiskal MD of the University of California at San Diego and other leading authorities in support of the proposition that there can be bipolar disorder without hypomania or mania, what some experts are calling 'soft' bipolar disorder.
Basically, look at the nature of the depression. Short and frequent recurrent depressions (as opposed to chronic depression) are a potential giveaway. Rather than view these depressions as discrete episodes that come and go, it may be more helpful to see them as part of a cycle. So what if 'up' is more like normal? We still have evidence of a roller coaster, albeit one of a subterranean variety.
Other indicators are depressions with atypical features (such as mood reactivity), and postpartum and psychotic depressions. A first degree relative with bipolar disorder is also a good sign.
Are We Really Talking About Recurrent Depression Instead?
Frederick Goodwin MD, co-author of the definitive book on bipolar disorder, is inclined to classify these soft bipolar cases as depression, but not in the ordinary sense. The DSM distinction between unipolar and bipolar, in his words, 'turned Kraepelin on his head.'
Emil Kraepelin is the legendary diagnostician who first coined the term manic depression (not to be confused with the term bipolar disorder). In Kraepelin's system, Dr Goodwin explained to this writer, 'affective disorders were divided into the highly recurrent and the less recurrent or non-recurrent forms.'
So what Kraepelin meant by manic depressive illness was 'recurrent affective disorder.' There was no distinction between 'uni' and 'bi.' It was more useful, instead, to conceive of one's illness as occupying part of a continuous spectrum..
But this is not the same as saying all depressions are alike, much less to be treated the same. All the research groups that did the original work on unipolar-bipolar differences were working with recurrent patients. This included Dr Goodwin and his colleagues, who, in a seminal 1976 study, teased out a group of patients with characteristics they defined as 'bipolar II.'
Dr Goodwin used bipolar II to distinguish this form of mood disorder from unipolar disorder and bipolar I. Nevertheless, in all cases it was understood by all concerned that they were dealing with various types of recurrent depression. The original meaning of unipolar, says Dr Goodwin, 'was one form of recurrent affective disorder.'
Later investigators separated manic depressive disorder into unipolar and bipolar, based on the presence or absence of mania or hypomania. But, as Dr Goodwin explains:
'Once the DSM separated bipolar disorder out from the beginning, it left unipolar as a relatively meaningless term - that is, everything that's not bipolar. The DSM-IV residual category of 'recurrent unipolar' is not much help because all that means is more than one episode.'
One of the implications of abandoning Kraepelin, according to Dr Goodwin, is 'that my friend Hagop Akiskal is more or less forced to put the highly recurrent unipolar patients in the 'bipolar spectrum' even though they are not bipolar. Given the DSM-IV, that seems to be the only way to emphasize their close relationship to bipolar disorder (family history of mania, early age of onset, multiple episodes).'
Focus on the Cycling
So we are talking about a group of patients with highly recurrent depressions, who may or may not have bipolar disorder but who have a lot in common with those who do.
The bottom line tends to be how these individuals react to antidepressants. An individual with highly recurrent depression or soft bipolar may run a similar risk of switching into mania or hypomania as one with more obvious bipolar symptoms. Or, as in the case with many bipolar patients, the antidepressant may poop out or have no clinical benefit whatsoever, even after three attempts on different antidepressants.
'By its very nature,' Dr Phelps tells us, 'bipolar disorder is a problem of cyclic changes in mood and energy.' Therefore, Dr Phelps advises, focus on the long-term goal of stopping the cycling and 'try to avoid treating your symptom du jour.' The object is to keep depression from returning and not make the cycling worse.
It’s helpful to start, Dr Phelps advises, by being mindful of the stabilizing influences in our lives, such as adequate sleep, good social connections, proper diet, and exercise. Lord knows, we can count on a host of destabilizing influences to arrive on our doorsteps.
It may be best to ride out a depression, if possible, Dr Phelps suggests, rather than try an antidepressant. Bipolar depressions tend to be of shorter duration, so once the depression resolves, meds strategies can concentrate on keeping depressions from returning. Mood stabilizers are the treatment of choice, some with demonstrated efficacy in preventing relapse into a depressive episode.
Intriguingly, Dr Goodwin notes: 'It's quite revealing to look at the old lithium data; it's as effective in the prevention of highly recurrent unipolar as it is in bipolar; so this particular mood stabilizer should be viewed as an anti-cyclic agent, not just an antibipolar agent.'
For those with bipolar (and highly recurrent) depressions, antidepressants need to be regarded with suspicion, as these meds tend to treat the symptom at the expense of the cycle. Switches into mania and hypomania are common. Ironically, Dr Phelps maintains, antidepressants may result in more depression. This is because antidepressants, as well as causing cycling, may shorten the intervals between cycles.
Psychotherapy is also crucial. These include cognitive-behavioral therapy and interpersonal therapy. Dr Phelps also urges 'prodrome detection,' which involves being acutely attuned to early warning signs of an impending episode, and 'social rhythm therapy' for normalizing sleep."
'In the DSM mode of thinking,' Dr Phelps tells us, 'making an accurate diagnosis requires determining whether the patient with depression symptoms is unipolar or bipolar, whereas in the Mood Spectrum approach, we clinicians don’t ask what might be the most accurate label for you. Instead, we ask where might your symptoms lie on the Mood Spectrum. … Instead of saying yes or no as to whether you might have bipolar disorder [we] try to determine how much bipolarity you have.'
The diagnostic threshold for bipolar II is hypomania, but here’s the catch: Hypomania is often barely discernible, especially in a population that may spend 50 days depressed for every one day hypomanic. A walk on the wild side for some may be using real butter on their toast.
Dr Phelps cites Hagop Akiskal MD of the University of California at San Diego and other leading authorities in support of the proposition that there can be bipolar disorder without hypomania or mania, what some experts are calling 'soft' bipolar disorder.
Basically, look at the nature of the depression. Short and frequent recurrent depressions (as opposed to chronic depression) are a potential giveaway. Rather than view these depressions as discrete episodes that come and go, it may be more helpful to see them as part of a cycle. So what if 'up' is more like normal? We still have evidence of a roller coaster, albeit one of a subterranean variety.
Other indicators are depressions with atypical features (such as mood reactivity), and postpartum and psychotic depressions. A first degree relative with bipolar disorder is also a good sign.
Are We Really Talking About Recurrent Depression Instead?
Frederick Goodwin MD, co-author of the definitive book on bipolar disorder, is inclined to classify these soft bipolar cases as depression, but not in the ordinary sense. The DSM distinction between unipolar and bipolar, in his words, 'turned Kraepelin on his head.'
Emil Kraepelin is the legendary diagnostician who first coined the term manic depression (not to be confused with the term bipolar disorder). In Kraepelin's system, Dr Goodwin explained to this writer, 'affective disorders were divided into the highly recurrent and the less recurrent or non-recurrent forms.'
So what Kraepelin meant by manic depressive illness was 'recurrent affective disorder.' There was no distinction between 'uni' and 'bi.' It was more useful, instead, to conceive of one's illness as occupying part of a continuous spectrum..
But this is not the same as saying all depressions are alike, much less to be treated the same. All the research groups that did the original work on unipolar-bipolar differences were working with recurrent patients. This included Dr Goodwin and his colleagues, who, in a seminal 1976 study, teased out a group of patients with characteristics they defined as 'bipolar II.'
Dr Goodwin used bipolar II to distinguish this form of mood disorder from unipolar disorder and bipolar I. Nevertheless, in all cases it was understood by all concerned that they were dealing with various types of recurrent depression. The original meaning of unipolar, says Dr Goodwin, 'was one form of recurrent affective disorder.'
Later investigators separated manic depressive disorder into unipolar and bipolar, based on the presence or absence of mania or hypomania. But, as Dr Goodwin explains:
'Once the DSM separated bipolar disorder out from the beginning, it left unipolar as a relatively meaningless term - that is, everything that's not bipolar. The DSM-IV residual category of 'recurrent unipolar' is not much help because all that means is more than one episode.'
One of the implications of abandoning Kraepelin, according to Dr Goodwin, is 'that my friend Hagop Akiskal is more or less forced to put the highly recurrent unipolar patients in the 'bipolar spectrum' even though they are not bipolar. Given the DSM-IV, that seems to be the only way to emphasize their close relationship to bipolar disorder (family history of mania, early age of onset, multiple episodes).'
Focus on the Cycling
So we are talking about a group of patients with highly recurrent depressions, who may or may not have bipolar disorder but who have a lot in common with those who do.
The bottom line tends to be how these individuals react to antidepressants. An individual with highly recurrent depression or soft bipolar may run a similar risk of switching into mania or hypomania as one with more obvious bipolar symptoms. Or, as in the case with many bipolar patients, the antidepressant may poop out or have no clinical benefit whatsoever, even after three attempts on different antidepressants.
'By its very nature,' Dr Phelps tells us, 'bipolar disorder is a problem of cyclic changes in mood and energy.' Therefore, Dr Phelps advises, focus on the long-term goal of stopping the cycling and 'try to avoid treating your symptom du jour.' The object is to keep depression from returning and not make the cycling worse.
It’s helpful to start, Dr Phelps advises, by being mindful of the stabilizing influences in our lives, such as adequate sleep, good social connections, proper diet, and exercise. Lord knows, we can count on a host of destabilizing influences to arrive on our doorsteps.
It may be best to ride out a depression, if possible, Dr Phelps suggests, rather than try an antidepressant. Bipolar depressions tend to be of shorter duration, so once the depression resolves, meds strategies can concentrate on keeping depressions from returning. Mood stabilizers are the treatment of choice, some with demonstrated efficacy in preventing relapse into a depressive episode.
Intriguingly, Dr Goodwin notes: 'It's quite revealing to look at the old lithium data; it's as effective in the prevention of highly recurrent unipolar as it is in bipolar; so this particular mood stabilizer should be viewed as an anti-cyclic agent, not just an antibipolar agent.'
For those with bipolar (and highly recurrent) depressions, antidepressants need to be regarded with suspicion, as these meds tend to treat the symptom at the expense of the cycle. Switches into mania and hypomania are common. Ironically, Dr Phelps maintains, antidepressants may result in more depression. This is because antidepressants, as well as causing cycling, may shorten the intervals between cycles.
Psychotherapy is also crucial. These include cognitive-behavioral therapy and interpersonal therapy. Dr Phelps also urges 'prodrome detection,' which involves being acutely attuned to early warning signs of an impending episode, and 'social rhythm therapy' for normalizing sleep."
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