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The authors’ observations
The persistence of Ms. R’s depressive symptoms suggests comorbid major depressive disorder (MDD). In fact, MDD and GAD are considered the most common mood-anxiety comorbidities.2
Determining whether Ms. R has unipolar depression or bipolar disorder is extremely important, considering the treatment implications. In patients with bipolar disorder, any antidepressant can trigger mania or hypomania if used without a mood stabilizer. Some studies also have associated rare cases of suicidal behavior with antidepressant use.3,4 Lifetime risk of suicide in bipolar disorder is approximately 20 times that in the general population.5
Although Ms. R’s history does not reveal a previous manic episode, ruling out hypomania is difficult because it usually does not impair work or social functioning. Hypomania often goes unreported because others hardly notice it. Collateral history can uncover clues to hypomania (See For Your Patient), but Ms. R’s husband and daughters say they have not seen such episodes.
On the other hand, normal behavior can be mistaken for hypomania. Ms. R’s previous psychiatrist and primary care physician might have misinterpreted Ms. R’s baseline extroverted personality as hypomanic behavior. Also, her over-whelming depressive and anxiety symptoms between depressive episodes made her normal moods appear hypomanic.
Compared with unipolar depression, bipolar depression is more frequently associated with psychomotor retardation, hypersomnia, early onset, and family history of bipolar disorder.6 Ms. R, however, suffered low energy, terminal insomnia, and late onset, and had no known family history of bipolar disorder.
The Mood Disorder Questionnaire, a scale of self-administered questions, can help screen for symptoms that suggest bipolar disorder. A positive questionnaire result demands further clinical evaluation.7
For Your Patient
Depression, mania, or hypomania? Signs family, friends should not miss*
Patient could be depressed if he/she:
- is constantly sad or irritable
- seems lost, withdrawn, or isolated
- is preoccupied with negative ideas and concerns
- persistently feels guilty, hopeless, and helpless
- says he or she has considered suicide
- has not been showering regularly or is unkempt (indicates low mood)
- shows significant changes in sleep
- moves slowly or sparingly, as if “slowed down” (indicates depressed affect)
- is often restless (indicating agitated/anxious depression)
- talks in a low-tone or monotone voice
- no longer enjoys activities or hobbies he or she once found pleasurable
- shows significant changes in appetite
- no longer enjoys sex
- cannot concentrate or make decisions
Patient could be manic or hypomanic if he/she:
- seems abnormally hyperactive, restless, and energized, compared with normal self
- is inappropriately euphoric and jubilant or, on occasion, extremely irritable
- talks rapidly and excessively
- often wears clothes that are too bright or colorful
- seems unusually self-confident, grandiose, and highly distractible
- shows increased sexual desire
- is impulsive, increasingly daring, and shows seriously impaired judgment, such as by investing/spending large sums of money for ill-advised reasons
- seems energetic despite lack of sleep
*If a family member shows any of the above symptoms, get him or her to a mental health clinic as soon as possible. Take the family member to the nearest ER or call your local crisis unit or 911 if you suspect the family member might hurt him/herself or others.
Continued treatment: ‘normal’ again
In addition to the HAM-D, we also administer the Mood Disorder Questionnaire. Results suggest Ms. R does not have bipolar illness.
To address Ms. R’s depressive symptoms, we start the selective serotonin reuptake inhibitor escitalopram at a low dosage (5 mg/d) to avoid exacerbating her anxiety. We discuss the drug’s potential to induce mania, hypomania, or other adverse effects such as nausea, anxiety, sleep disturbance, headache, and sexual dysfunction. Buspirone is maintained at 15 mg bid.
Two weeks later, Ms. R reports some increase in energy and motivation. After another 2 weeks, she reports significantly improved mood and concentration. She consistently falls asleep at 10 PM and sleeps 8 hours each night. She also finds time to read and go out with her friends and she gets along more amicably with her daughters and husband.
One month later, we increase escitalopram to 10 mg/d, a normal therapeutic dosage. Ms. R continues to respond positively and reports no side effects. Two months after starting the antidepressant, her HAM-D score of 8 suggests normal mood. We decrease follow-up visits to once monthly.
At a subsequent visit, Ms. R tells us she wants to find a job. A month later, she says she is enjoying her new job in a department store. Over the next 6 months, she remains free of anxiety, depressive symptoms, hypomanic behavior, and side effects. She tells us it’s nice to feel “normal” again.
We reduce Ms. R’s appointments to every 3 months. After another year, we refer her back to her primary care physician at her request.
The authors’ observations