From the Editor Misdiagnosing bipolar disorder as major depressive disorder The therapeutic consequences can or move to a monoamine oxidase inhibitor. If be depressing! that does not work, perform electroconvul- sive therapy (ECT). A study published recently found a dif- Quite a few depressed patients actu- ference in brain blood flow between ally worsened on antidepressant drugs, unipolar depression, also known as becoming agitated, irritable, and an- Henry A. Nasrallah, MD major depressive disorder (MDD), and gry—yet clinicians did not recognize Editor-in-Chief the depressive phase of bipolar I (BD I) that change as a switch to irritable ma- and bipolar II (BD II) disorders, known nia or hypomania, or a mixed depressed as bipolar depression.1 Researchers state. In fact, in those days, patients suf- performed arterial spin labeling and fering mania or hypomania were ex- submitted the resulting data to pattern pected to be euphoric and expansive, During my residency, recognition analysis to correctly classify and the fact that almost one-half of bipo- I was never urged 81% of subjects. This type of investiga- lar mania presents with irritable, rather tion augurs that objective biomarkers than euphoric, mood was not widely to distinguish if a might halt the unrelenting misdiagnosis recognized, either. depression is unipolar of bipolar depression as MDD and end I recall psychodynamic discussions the iatrogenic suffering of millions of bi- as a resident about the anger and hostil- or bipolar because polar disorder patients who became vic- ity that some patients with depression the treatment was the tims of a “therapeutic misadventure.” manifest. It was not widely recognized same! It is perplexing that this problem has that treating bipolar depression with festered so long, simply because the two an antidepressant might lead to any types of depression look deceptively of four undesirable switches: mania, alike. hypomania, mixed state, or rapid cy- cling. We saw patients with all of these complications and simply labeled their This takes me back to my days condition “treatment-resistant depres- in residency sion,” especially if the patient switched Although I trained in one of the top to rapid cycling with recurrent de- psychiatry programs at the time, I was pressions (which often happens with never taught that I must first classify my BD II patients who receive antidepres- depressed patient as unipolar or bipolar sant monotherapy). before embarking on a treatment plan. Frankly, BD II was not on our radar To comment on this editorial or other topics of interest, Back then, “depression was depression” screen, and practically all such patients visit www.facebook.com/ and treatment was the same for all de- were given a misdiagnosis of MDD. No CurrentPsychiatry, or go to pressed patients: Start with a tricyclic an- wonder we all marveled at how ECT fi- CurrentPsychiatry.com and click on the “Contact Us” link. tidepressant (TCA). If there is no response nally helped out the so-called treatment- within a few weeks, consider a different TCA resistant patients! Current Psychiatry 20 October 2013 Editorial Staff Sadly, the state of the art treatment A new age of therapeutics EDITOR John Baranowski of bipolar depression back then was In the past few years, we’ve witnessed MANAGING EDITOR Erica Vonderheid actually a state of incomplete knowl- the development of several pharmaco- ASSOCIATE EDITOR Hina Khaliq edge. Okay—call it a state of ignorance therapeutic agents for bipolar depres- Art & Production Staff wrapped in good intentions. sion. First, the olanzapine-fluoxetine CREATIVE DIRECTOR Mary Ellen Niatas combination was approved for this in- ART DIRECTOR Pat Fopma dication in 2003. That was followed by DIRECTOR, JOURNAL MANUFACTURING The dots did not get quetiapine monotherapy in 2005 and, Michael Wendt PRODUCTION MANAGER Donna Pituras connected… most recently, in 2013, lurasidone (both There were phenomenologic clues that, as monotherapy and as an adjunct to a Publishing Staff had we noticed them, could have cor- mood stabilizer). PUBLISHER Sharon J. Spector rected our clinical blind spot about the With those three FDA-approved op- MARKETPLACE ACCOUNT MANAGER Linda Wilson ways bipolar depression is different tions for bipolar depression, clinicians DIRECTOR OF NEW MEDIA Amy Park from unipolar depression. Yet we did can now treat this type of depression CONFERENCE MARKETING MANAGER not connect the dots about how bipolar without putting the patient at risk of Kathy Wenzler depression is different from MDD (see complications that ensue when anti- Subscription Services: (800) 480-4851 this article at CurrentPsychiatry.com depressants approved only for MDD Editor-in-Chief Emeritus for a Table that lists those differences). are used erroneously as monotherapy James Randolph Hillard, MD Treatment clues also should have for bipolar depression. opened our eyes to the different types of These days, psychiatry residents Quadrant HealthCom Inc. depression: are rigorously trained to differentiate PRESIDENT AND CEO Marcy Holeton John Baranowski unipolar and bipolar depression and EDITORIAL DIRECTOR VICE PRESIDENT, MULTICHANNEL CUSTOM Clue #1: Patients with treatment-resis- to select the most appropriate, evi- SOLUTIONS Margo Ullmann tant depression often responded when dence-based treatment for bipolar VICE PRESIDENT, EVENTS David Small lithium was added to an antidepres- depression. The state of ignorance sur- Frontline Medical Communications sant. This led to the belief that lithium rounding this psychiatric condition CHAIRMAN Stephen Stoneburn has antidepressant properties, instead is lifting, although there are pockets CFO Douglas E. Grose of clueing us that treatment-resistant of persisting nonrecognition in some PRESIDENT, CUSTOM SOLUTIONS depression is actually a bipolar type of settings. Gaps in knowledge under- JoAnn Wahl depression. pin and perpetuate hoary practices, VICE PRESIDENT, CUSTOM PROGRAMS Carol J. Nathan but innovative research—such as the CORPORATE CIRCULATION DIRECTOR Clue #2: Likewise, patients with treat- study cited here on brain blood-flow Donna Sickles ment-resistant depression improved biomarkers—is the ultimate antidote CORPORATE DIRECTOR, MARKETING when an antipsychotic agent, which is to ignorance. & RESEARCH Lori Raskin also anti-manic, was added to an antide- pressant (seasoned clinicians might re- member the amitriptyline-perphenazine combination pill, sold as Triavil, that was 7 Century Drive, Suite 302 a precursor of the olanzapine-fluoxetine Henry A. Nasrallah, MD Parsippany, NJ 07054 combination developed a few years ago Editor-In-Chief Tel: (973) 206-3434 to treat bipolar depression). Fax: (973) 206-9378 www.qhc.com Reference Clue #3: ECT exerted efficacy in pa- 1. Almeida JR, Mourao-Miranda J, Aizenstein HJ, et al. Published through tients who failed an antidepressant or Pattern recognition analysis of anterior cingulated an educational who got worse taking one (ie, switched cortex blood flow to classify depression polarity partnership with [published online August 22, 2013]. Br J Psychiatry. to a mixed state). doi: bjp.bp.112.122838. Current Psychiatry Vol. 12, No. 10 21 From the Editor Table Bipolar depression is phenomenologically distinct from major depressive disorder Unlike a patient with major depressive disorder, a patient with bipolar I or bipolar II disorder: • has a history of hypomanic episodes • often has a first-degree family history of bipolar mania or hypomania • often has an earlier age of onset (teenage years or 20s) tends to have an abrupt onset, rather than a gradual one • can have a rapid symptomatic recovery (flight to health) within a few days—not gradually, over several weeks • tends to have a history of multiple episodes • can present with psychotic features during adolescent-onset depression • often manifests reversed (atypical) vegetative signs (hypersomnia and weight gain instead of insomnia and weight loss) • often associated with alcohol and stimulant abuse • often associated with comorbid anxiety disorders (generalized anxiety disorder, panic attacks, social anxiety disorder, or obsessive-compulsive disorder) • often has a history of hedonistic activities (eg, multiple sex partners, auto racing, gambling) • might present with retarded, stuporous depression or, even, catatonia • is equally likely to be male as female (unlike the preponderance of females in major depressive disorder) Current Psychiatry Vol. 12, No. 10 A.