Major Depressive Disorder and Bipolar Mood Disorders
“Whatever you are, be a good one.” – Abraham Lincoln.
A 30 year old woman was brought with chief complain of profuse vomiting and nausea after attempting suicide with 8 Acetaminophen pills. The patient appeared tired, sad, her hair was messy and her clothes were rumpled. Throughout the interview session her expressions were flat and she spoke in a soft voice giving unelaborated responses to the examiner’s questions. When asked about the reason behind the act of attempting suicide, patient admitted it was due to the problems she was facing with her spouse. She denied consuming alcohol or smoking. She said she only consumes one glass of coffee every morning which is her only visible addiction.
Epidemiological studies suggest that the mean age of illness onset is earlier among bipolar patients than among those with major depressive disorder, with one study estimating a mean difference of 6 years.
Major depressive episodes are characteristic of both major depressive disorder and bipolar disorder. Diagnostic criteria rely on features, of course—namely, the presence or absence of manic or hypomanic episodes—to distinguish between the two diagnoses. In some cases, however, a history of mood elevation is under reported by patients; in others, patients who appear to be in a depressive episode simply have not yet experienced a manic episode. Initial misdiagnosis is common, and delayed or inappropriate treatment can be associated with consequences, including switching into mania, precipitation of a mixed state, more frequent mood episodes, or poorer outcome in general
Patient claimed to have a happy marriage until lately about a month ago when patient found out that her husband was having an affair with one of his fellow colleague. Since then, patient experiences commotions with her husband every other day and at times, it gets extreme where patient suffered from domestic violence. Patient did admit that the suffered bruises as a result of husband hitting her. According to patient, she was still having hopes that their marriage will work out till three weeks back when the husband told her that he wants to marry the colleague that he was having affair with. Quoting the patient, her husband’s announcement caused her to loss interest in anything and everything. She was neither able to perform her daily household chores nor carry on with her responsibility as a mother.
Depression can often be triggered by very stressful life situations or other factors such as
- The death of a loved one, a move, a divorce, financial difficulties or job loss.
- Social isolation.
- Periods of relationship conflict, whether marital or family-related.
- Demanding work or a stressful workplace.
- Health issues, especially when the person has a chronic health problem.
Sometimes the biggest hurdle to getting better and moving forward is the depression itself. For example, a depressed person often removes themselves from the presence of comforting and encouraging loved ones or ceases to participate in activities of personal interest as result of being depressed, which might further contribute to their condition.
Scientists define “environment” in the realm of mental illness broadly, some going so far as to suggest it encompasses everything that isn’t an inherited gene.
“It could be that these [gene–environment] interactions are more complex than our current knowledge allows us to imagine.”
She also complained on having trouble to fall asleep and even if managed to sleep, she could not maintain them for the similar hours she used to sleep. This means she has not been able to have a good continuous night sleep and this has been occurring for the past three weeks. Plus, her appetite has dropped drastically which was obvious when she loss almost 8 kg in just 3 weeks. However patient denied of having hallucination (seeing things that are not visible to others or hearing voices that are not audible to others). Patient claimed to be having these suicidal thoughts for past one week as she felt worthless and claims that there is no meaning to her life anymore.
Somatic symptoms of depression and anxiety—in particular, the somatic (muscular), respiratory, and genitourinary items from the HAM-A—were greater in the major depressive disorder group. The role of somatic symptoms has recently received renewed attention in major depressive disorder but has not been previously examined in bipolar disorder. Conversely, tension/edginess and fearfulness were more severe among subjects with bipolar disorder than among subjects with major depressive disorder.
Two hours prior to admission to hospital, the patient had a phone call from her husband saying that he’s going to legally divorce her, triggering the patient to succumb to the voices in her head, to end her life by consuming 8 Acetaminophen pills with a bottle of sprite.
Through the heteroanamnesis done with the patient’s parents, it was found that lately patient portrayed to be very passive and aloof. She locks up herself in her room for hours and refuses to respond to anyone even her own children.
As for medical history among family members, no records of family members suffering from psychiatric illness was found. There were no abnormalities found from the physical examination of the patient. Whereas from the psychiatric examination patient was found to have good orientation
towards time, place and people, there were no signs of diminished memory, and intelligence coherent with her education level.
Family and twin studies have established the familiality of bipolar disorder, so our finding that bipolar disorder is more common in family members of bipolar subjects is expected.
Family history of major depressive disorder did not differ significantly between the two; however, family history of bipolar disorder was more common among the subjects with bipolar disorder.
Any chronic condition can trigger depression, but the risk increases with the severity of the illness and the level of life disruption it causes. The risk of getting depression is generally 10-25% for women and 5-12% for men. However, those with chronic illnesses face a much higher risk — between 25-33%.
The rate for depression occurring with other medical illnesses is quite high:
- Heart attack: 40-65% experience depression
- Coronary artery disease (without heart attack): 18-20% experience depression
- Parkinson’s disease: 40% experience depression
- Multiple sclerosis: 40% experience depression
- Stroke: 10-27% experience depression
- Cancer: 15%-25% experience depression
- Diabetes: 25% experience depression
However patient appeared sad with teary eyes, obvious lack of concentration, minimal eye contact and speaks with a low tone. The mood and affect of the patient was depressive and appropriate, the forms of her thoughts was logical coherent and realistic with the presence of suicidal ideation.
Hallucinations and illusions were denied, and patient was found to be hypobulic, was suffering from late type insomnia. Patient appeared calm throughout the interview.
A number of studies have attempted to distinguish the phenomenology of depression in major depressive disorder and bipolar disorder. In bipolar depression, a greater prevalence of atypical features or reverse neurovegetative symptoms, such as hypersomnia or hyperphagia, was reported by most studies but not all. Likewise, a greater prevalence of melancholic symptoms among bipolar depressed patients was identified in several reports but not in others. Finally, irritability, anger, subthreshold mixed symptoms, such as overactivity, and psychosis have also been associated with bipolar depression. One prospective study suggested specificity with combinations of clinical predictors, such as early onset of symptoms, bipolar family history, and hypersomnia/slowing as high as 98%. These findings are derived from select samples, however, and they are rarely replicate.
Quite a few depressed patients actually worsened on antidepressant drugs, becoming agitated, irritable, and angry—yet clinicians did not recognize that change as a switch to irritable mania or hypomania, or a mixed depressed state. In fact, in those days, patients suffering mania or hypomania were expected to be euphoric and expansive, and the fact that almost one-half of bipolar mania presents with irritable, rather than euphoric, mood was not widely recognized, either.
Patient was diagnosed with major depressive disorder without the manifestation of psychotic features based on the DSM IV guidelines.
She was admitted in Hospital and was being treated with the combination drug such as the antidepressant (fluoxentine 20mg) and psychotherapy as well. The family members inclusive of the patient’s children were given psychoeducation in order to speed up patient’s recovery. The patient’s condition improved after two weeks of observation in the psychiatric ward and patient denied of having suicidal ideation any longer. Patient was discharge 11 days from the day of admission.
Delayed recognition of bipolar disorder appears to be common, even in more recent investigations. For misdiagnosed bipolar patients, when mood stabilizer initiation is delayed, outcomes appear to be poorer. Exposure to antidepressants, particularly in the absence of mood stabilizers, can precipitate switching into manic or mixed states or cycle acceleration in a subset of bipolar patients. Conversely, although rarely discussed in the literature, patients with major depressive disorder exposed to mood stabilizers unnecessarily likewise would be expected to suffer poorer outcomes because of side effects or lesser likelihood of treatment response. Therefore, distinguishing patients with major depressive disorder from patients with bipolar disorder in a depressive episode is of profound clinical importance.
In summary, this comparative study suggests that in addition to age at onset, recurrence, and family history, individual symptoms—particularly those related to anxiety, both somatic and cognitive—may be useful in distinguishing bipolar disorder from major depressive disorder. Although no individual symptom discriminates between diagnoses, it was possible to construct a model with significant predictive value.
Based on DSM IV criteria, there must be at least expression of five of the symptoms which occurs for a period of 2 weeks. [1, 2] Patient in this case happen to portray symptoms like depressive mood, loss of appetite and weight, loss of pleasure, worthlessness, insomnia and on top of all suicidal
ideation. The symptoms were present for more than 2 weeks which fits the diagnosis of major depression. Through the anamnesis it was found that there was no history of hallucination or illusion which rules out the possibility of having major depression disorder with psychotic features.
THE WORST PART ABOUT DEPRESSION; PEOPLE WHO DON’T HAVE IT, THEY JUST DON’T GET IT.