Differentiating Depression and Bipolar Depression
M. Joyce Sasse DNP APRN PMHNP-BC PMHCNS-BC
About BHECN
The Behavioral Health Education Center of Nebraska (BHECN, pronounced “beacon”) was created by the Legislature to
address the shortage of behavioral health professionals in rural and underserved areas. BHECN recruits & educates students in
behavioral health and trains & retains professionals in the workforce.
By increasing the number of behavioral health professionals, improving accessibility of behavioral health care, and building
competence of the workforce, we are improving the health of all Nebraskans.
Learn more at unmc.edu/bhecn
Keep up with the latest
events and trainings from BHECN:
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About the Mental & Behavioral Health Care Webinar Series
Individual webinars will focus on common psychiatric disorders using a holistic
approach to include cultural awareness, spirituality, interdisciplinary collaboration,
psychopharmacology, and principles of recovery.
Acknowledgements
BHECN would like to acknowledge the collaboration with the American Psychiatric
Nurses Association, NE Chapter (APNA-NE) in the development and implementation
of this educational series.
Learn more at: www.apna.org
Differentiating Depression and Bipolar Depression
M. Joyce Sasse DNP APRN PMHNP-BC PMHCNS-BC
Conflict of Interest Disclosure
Dr. Sasse is the president and sole owner of Joyce K Sasse NP, PC, which
manages her private psychiatric practice, consulting, and educational nursing
activities.
Dr. Sasse has no other financial interests or conflicts with other organizations or
entities that will detract from the balance, independence, objectivity, or scientific
rigor of this program.
Off-Label Use of Medications
Dr. Sasse will mention off-label uses for medications in her lecture
Handouts for this program can be downloaded under the “Handouts” tab in your
GoToWebinar gray control box
Handouts clearly label any off-label use of medications, recourses, and other
information for the participants.
Poll Question
Is the following statement true or false?
People who commit suicide are mentally ill.
Depression in General
In the U.S., 6-12% of the population will suffer from depression sometime during its
life.
Suicide is the eighth-leading of cause of death in the U.S.
Almost all people who complete a suicide have a diagnosable mental disorder with or
without substance abuse, and substance abuse is often a form of self- medicating
depression.
(Andrew 2014)
Suicide
In 2005, suicides accounted for 1.4% of all deaths worldwide. This statistic is low
because many suicides go unreported for many reasons.
Sadly, over 60% of people who commit and complete suicide have seen a doctor
within 30 days of the event.
(Andrew 2014)
Depression
People with depression are more likely to suffer from:
• Type 2 diabetes and cardiovascular disease
• Unipolar depression. (Unipolar depression is projected to be the second-leading
cause of disability worldwide.)
(Andrew, 2014)
Unipolar Depression
66% of people with depression don’t know they have a treatable illness and don’t
look for treatment.
50% of persons diagnosed with major depression receive any kind of treatment.
20% of those individuals receive treatment that meets current practice guidelines.
(Gonzales, Vega, Williams et al. 2010)
Bipolar Depression
Lifelong prevalence of Bipolar Disorder in the U. S. is between 3.7% and 3.9%.
•
•
•
•
Bipolar Disorder Type I (BPI) (1.0%)
Bipolar Disorder Type II (BPII) (1.1%)
Sub-threshold Bipolar Disorders (2.4-4.7%)
International prevalence (5-7%)
(Soreff, 2015)
Bipolar Depression
15% of all persons suffering from Bipolar disorders will commit suicide
36.3% risk of suicide–25% of all completed suicides
(American Psychiatric Association, 2013)
Poll Question
Is the following statement true or false?
Science is close to isolating the two genes that control
depressive and manic behaviors.
Isn’t All Depression the Same?
“Modern genomics suggests that the spectrum is not a single disease, but a
complex of hundreds if not thousands of different diseases, with overlapping
genetic, epigenetic, and biomarkers as well as clinical symptoms and functional
outcomes.”
(Stahl 2013)
Brain SPECT Scans
Chromosome 12
Chromosome 10
Two genetic variants on Chromosome 10 found in women with recurrent Major
Depressive Disorder: one near SIRT1 & one at LHPP
In a further analysis of women with severe MDD, a stronger genetic signal
appeared at SIRT1
(Cai, Chang, Li, & Li, et al. 2015)
Depression Odds
50% Unipolar Depression
2% Bipolar I Disorder
15% Bipolar II Disorder
33% Bipolar Spectrum Disorder
(Stahl 2013)
How to Tell Them Apart
Depression is the common subset of symptoms between Unipolar and Bipolar
Spectrum Disorders.
Symptomatic persons of both disorders spend most of their time in the depressed
state.
Depression is the symptom that most often brings the person in for treatment.
(LeBano 2015)
Information Sources
Family History/Genetics
Close Family Members
Age of Onset of Symptoms
Response to Psychiatric Medications
Symptom Observation and Questions
Tests: Young Mania Rating Scale, Hamilton Depression Scale, et al
(Hegerl, Bottner, Holtschmodt-Taschner, et al, 2008, Stahl 2013,Vieta, SanchezMoreno, Lahuerta, et al 2008, Zimmerman, Ruggero, Chelminski & Young 2008)
Social History
Social History (Environmental Influences, Moves and Reasons, Housing Conditions)
Military Hx
Family Dynamics/Demographic and Historical Information
Parents
Siblings
Married
Children
Significant Other
Friends
Losses in Last 12 Months
Spiritual Preference
Social History
Environmental Influences, Moves and Reasons, Housing Conditions
• What in your background from childhood, school or your past brings you here
today
• Or can help me understand you better,
• Or help me understand the problems you bring today better
Birth/Adoptive Family
Family Dynamics/Demographic and Historical Information
• Parents:
– Names, where they live, and if the patient has emotional attachment to them
• Siblings:
– How many, birth order, and if the patient has emotional attachment to them
Nuclear Family
Married: Spouse, marital status, number of children from this marriage , and if
any, their whereabouts
Children: First name and ages
Significant Other: Name and how long together
Outside Attachments
Friends: Do you have any friends that you consider your emotional support
group?
Losses in Last 12 Months
Spiritual Preference
Mental Health History
Family Hx
Hospitalizations
Past Tx: Medication
Therapy
Current Symptoms
Current Tx
Psychiatrist
Therapist
Family Psychiatric History
In your blood-related family, have there been any members who:
• Had psychiatric diagnoses from medical providers?
• Received treatment with psychiatric medications?
• Been hospitalized for psychiatric reasons?
• Had possible undiagnosed mental health problems?
Psychiatric Hospitalizations
Have you ever been hospitalized overnight for psychiatric reasons?
• What was your diagnosis or the reason for the admission?
• Did you receive any medication or special treatments?
• Do you know the name of the doctor who treated you at the hospital?
Past Treatment: Medication
What psychiatric medications have you been on in the past?
• How did each of these work for you?
• What are you current psychiatric medications?
• How are your current psychiatric medications working for you?
Past Treatment: Therapy
Have you seen a Therapist or a Counselor?
•
Where and when?
•
Why did you see the therapist or a counselor?
•
Are you currently in therapy or counseling?
•
If so, for what reason(s)?
Current Psychiatric Symptoms
Begin with Historical Questions
•
When was the first time you ever remember being depressed?
•
What caused it?
•
How long did that episode last?
•
How many other depressive episodes have you had?
Current Psychiatric Symptoms
During those depressed episodes, did you ever have an abrupt change of mood
where you were giddy/happy or hyper-irritable?
•
Did the mood change period go on for two days, one week, or longer?
•
During that period, did you have an inflated self-esteem or grandiosity?
•
Did you have a decreased need for sleep without loss of energy?
Current Psychiatric Symptoms
During those depressed episodes, did you ever have an abrupt change of mood
where you were giddy/happy or hyper-irritable?
•
Did you have an increase in goal-directed activity?
•
Were you more talkative than usual, talking faster than usual, or did you talk
to more people than usual?
•
Did you have ideas race through your head that went so fast, you could not
keep up with them?
Current Psychiatric Symptoms
During those depressed episodes, did you ever have an abrupt change of mood
where you were giddy/happy or hyper-irritable?
•
Were you more distractible than usual?
•
Did you feel more distractible than usual, use more alcohol or drugs, or did
you feel more agitated than usual?
•
Did you have a high involvement in risky behaviors or do things that were
fun but could have resulted in painful consequences?
Current Psychiatric Symptoms
In the past two weeks, have you:
•
Been depressed most of the day, most every day?
•
Had a markedly diminished joy or interest in all or almost all activities, or
can you still find joy in life?
•
Been able to perform all of your daily activities without a struggle?
Current Psychiatric Symptoms
In the past two weeks, have you:
•
Had a change in appetite or change in weight that you did not plan?
•
Had any trouble with sleeping: falling asleep, waking during the night, or
waking up early?
•
Have you awakened refreshed?
Current Psychiatric Symptoms
In the past two weeks, have you:
•
Felt fatigued or had a loss of energy nearly every day?
•
Felt agitated nearly every day?
•
Had feelings of worthlessness or excessive guilt?
Current Psychiatric Symptoms
In the past two weeks, have you:
•
Had trouble with thinking, concentration, memory, or the ability to make
decisions?
•
Had recurrent thoughts about death, suicidal ideations, or a plan to commit
suicide? Have you ever attempted suicide?
Current Psychiatric Symptoms
In the past two weeks, have you:
•
Had any homicidal thoughts or plans?
•
Had panic attacks, anxiety attacks, or constant feelings of anxiety? If so:
-What are the symptoms?
-What triggers them?
-What helps them to get better?
Current Psychiatric Symptoms
Continue asking questions to cover:
•
Obsessive-Compulsive Disorder
•
Eating Disorder
•
Hallucinations
•
Derealization
•
Self-Harm
-Do you feel the need to cut, burn, or self-harm in any way to reduce internal
pain or distress?
Poll Question
Is the following statement true or false?
Alcoholism is a disease that is regulated by one’s
genetic makeup.
Substance Abuse History
Family CD Hx:
Client Use: alcohol, street drugs or abuse of prescription drugs
•
Drug of Choice
•
First Use
•
Last Use
Substance Abuse History
Client Use:
•
Do you feel you have a problem with drugs or alcohol?
•
Treatment History
•
Collateral Information
Further Information
Have the patient take some of the objective tests
Ask the patient for permission to speak to family members for further information
Medication Treatment
Antidepressants
Lithium
Antipsychotics
Anticonvulsants
Others
Antidepressants
SSRIs
SNRIs
SSNRIs
Other
TCAs-Tri & Tetracyclics
MAOIs
Lithium
Effective for mania and prevention of mania
Somewhat effective with depression
Stabilizes mood
Helps prevent suicide in bipolar disorder
Augmenting agent for unipolar depression (off-label)
Antipsychotics
Atypicals
• Aripiprazole
• Quetiapine
• Lurasidone
• Respiradone
• Paliperidone
• Olanzapine and Olanzapine + Fluoxetine
• Ziprazidone
• Asenapine
Anticonvulsants
Valproate
Carbamazepine
Lamotrigine
Oxcarbazepine
Topiramate
Zonisamide
Gabapentin & Pregabalin
Levetiracetam
Others
Ketamine
Nimodipine-Calcium Channel Blockers
Benzodiazepines
Folate
(Bipolar Network News, 2015, Stahl, 2013)
Case:
30 year old male; c/o stress and depression
Mood:
Depressed and his affect is irritable.
Psychosocial:
States he is unmarried, h/o 1 divorce; 2 failed long
term relationships; no children; lives alone in a
rented apartment
Has always lived in this city. Father divorced his
mother when he was 10. Had trouble paying
attention in school; has difficulty with remembering
things. Graduated from high school. Was better at
sports than with academic work. Did not do well in
college and dropped out after his first semester. Is a
plumber's assistant in a family owned business.
Psych Hx:
Has never been on any psychiatric medications.
Was evaluated when he was younger and it was
suggested that he take medication for Attention
Deficit Disorder. His father refused to let him take
the medication so he did not receive or take them.
Family History:
Positive for a mother with bipolar disorder, a
maternal aunt with bipolar disorder, his father
suffered from what his mother thought was attention
deficit hyperactivity disorder and his older brother
has depression and moodiness.
Was first depressed when he was 8 years old and
he saw his parents fighting. His depression has
been off and on through his whole life with varying
severity. Wonders if there is any reason for him to
be alive but denies any suicide attempts. Has times
when he will become very irritable and angry-these
episodes will last for 3-4 days. During these time he
will not be like himself, When those days are over he
is more depressed than ever.
Poll Question
What else do you want to find out to help you make a
differential diagnosis(es) for James ?
References
American Psychiatric Association. (2013).Bipolar and related disorders. In American Psychiatric Association, Diagnostic and statistical
manual of mental disorders fifth edition (pp 123-154). Arlington, VA: American Psychiatric Publishing.
American Psychiatric Association. (2013).Depressive Disorders. In American Psychiatric Association, Diagnostic and statistical manual of
mental disorders fifth edition (pp 155-188). Arlington, VA: American Psychiatric Publishing.
Andrew, L.B. (2014). Depression and suicide. Medscape. Retrieved from http://emedicine.medscape.com/article/805459-overview#a2
Aziz, R., Lorberg, B., & Tampi. (2006, December). Treatments for late-life bipolar disorder. American Journal of Geriatric
Pharmacotherapy, 4(4) pp347-364
Andrew, L.B. (2014). Depression and suicide. Medscape. Retrieved from
http://emedicine.medscape.com/article/805459-overview#a2
Bipolar Network News.(2012, October) A genetic Risk factor for bipolar disorder: The CACNA1C gene.
Bipolar Network News. Retrieved from http://bipolarnews.org/index.php?s=Nimodipine
Bipolar Network News.(2012, October) A genetic Risk factor for bipolar disorder: The CACNA1C gene.
Bipolar Network News. Retrieved from http://bipolarnews.org/index.php?s=Nimodipine
Bipolar Network News.(2015, April) Gene CACNA1C is associated with early-onset bipolar disorder.
Bipolar Network News. Retrieved from http://bipolarnews.org/index.php?s=Nimodipine
Cai, N., Chang, S, Li, Y., Li, Q., Hu, J., Liang, J., Song, L., Kretzschmar, W., Gan, X., Nicod, J.,
Rivera, M., Deng, H., Du, B., Li, K., Sang, W., Gao, J., Gao, S., Ha., Ho H.Y., Hu, C., Hu, Z.,
Huang, G., Jiang, G., Jiang, T., Jin, W., Li. G., Li, K., Li, Y., Li, Y., Li, Y., Lin, YT., Liu, L., Liu, T., Liu,
Y., Liu, Y., Lu, Y., Lv. L., Meng, H., Qian, P., Sang, H., Shen, J., Shi, J., Sun, J., Tao, M., Wang, G.,
Wang, G., Wang, J., Wang, L., Wang, X., Wang, X., Yang, H., Yang L., Yin, Y., Zhang, J., Zhang, K.,
Sun, N., Zhang, W., Zhang, X., Zhang, Z., Zhong, H., Breen, G., Wang, J., Marchini, J., Cgen, Y.,
Xu, Q., Xu, X., Mott, R., Huang, G., Kendler, K., & Flint, J. (2015, May) Molecular signatures of
major depression. Current Biology, 25(9) pp1146-1156
Citrome, L (2014, December) Treatment of bipolar depression: Making sensible decisions. CNS
Spectrum, 19, pp4-12
Gonzalez, H.M., Vega, W.A., Williams, DR., Tarraf W., West, B.T., & Neighbors, H.W. (2010, January).
Depression care in the United Stated: Too little for too few. Archives of General Psychiatry, 67(1)
pp37-46
Hallowell, L.(Sen. Ed.). (2016) Nursing 2106 drug handbook. Philadelphia, PA: Wolters Kluwer
Hegerl,U., Bottner, A.C., Holtschmidt-Taschner, B., Born, C., Seemuller, F., Scheunemann, W.,
Schutze, M., Grunze, H., Henkel, V., Mergl, R., & Angst, J. (2008, July). Onset of depressive
episodes is faster in patients with bipolar versus unipolar depressive disorder: evidence from a
retrospective comparative study. Journal of Clinical Psychiatry, 69(7), pp1075-1080
Le Bano, L. (2015, July). How to differentiate bipolar disorder from unipolar depression. Psych
Congress Network. Retrieved from http://www.psychcongress.com/article/how-differentiate-bipolardisorder-unipolar-depression-12483.
O’Donovan, C., Garnham, J., Hajeck, T., & Alda. (2008, April). Antidepressant monotherapy in prebipolar depression; Predictive value and inherent risk. Journal of Affective Disorders, 107(1-3)
pp293-298
Papolos, D., Mattis, S., Golshan, S., & Molay, F.(@009, November). Fear of harm, a possible
phenotype of pediatric bipolar disorder: A dimensional approach to diagnosis for genotyping a
psychiatric syndromes. Journal of Affective Disorders, 118(1-3) pp28-38
Rosa, A., Andreazza, A., Kunz, M., Gomes, F., Santin, A., Sanchez-Moreno, J., Colom, F., Vieta, E., &
Kapczinski, F. (2008, April). Predominant polarity in bipolar disorder: Diagnostic implications.
Journal of Affective Disorders, 107(1-3) PP45-51
Smith, D., Griffiths, E., Kelly, M., Hood, K., Craddock, N., & Simpson, S. (2001, July). Unrecognized
bipolar disorder in primary care patients with depression. British Journal of Psychiatry, 199(1) pp
49-56
Soreff, S., (2015). Bipolar affective disorder. Medscape. Retrieved from
http://emedicine.medscape.com/article/286342-overview#a5
Stahl, S.M. (2013). Mood Disorders. In S. M. Stahl, Stahl’s essential psychopharmacology,
Neuroscientific basis and practical application (pp 237-283). New York, NY: Cambridge University
Press.
Stensland, M., Schultz, J. & Frytak, J. (2008, May), Diagnosis of unipolar depression following initial
identification of bipolar disorder: A common and costly misdiagnosis. Journal of Clinical Psychiatry,
69(5), pp749-758
Vieta,E., Sanchez-Moreno, J., Lahuerta, J., Zaragoza, S., (2008, April) Subsyndromal depressive
symptoms in patients with bipolar and unipolar disorder during clinical remission. Journal of
Affective Disorders, 107(1-3) 169-174.
Zimmerman, M., Ruggero, C.J., Chelminski, I., & Young, D. (2008, June). Is bipolar overdiagnosed?.
Journal of Clinical Psychiatry, 69(6) 935-940.
Images
CACNA1C Gene- Bipolar Network News October 30, 2012
SPECT scans of the brain-Brain Matters Imaging Centers 2007