Treatment resistant depression or bipolar II disorder?

Ok.. well where do I start?...............

I have always been told that I have treatment resistant depression. You name the medication and I've tried it... I've got to the stage that I have to keep a big list of the meds I have tried so that my psychiatrist doesn't waste my time by trying meon something which has already not worked!

Anyways..... I'm not your 'typical' depressed person or what my experience of depressed people has been like. My mood can fluctuate quite rapidly (often within a day) and although I do get great highs they are nowhere near as extreme as my lows (which usually require hospitalisation). Recently I have been reading articles which have suggested that a lot of those in my position may actually have bipolar disorder, or bipolar II to be more precise. Let me update you on what I've come across......

Several recent studies indicate that a substantial number of patients with bipolar depression, especially bipolar II depression, are initially diagnosed with unipolar major depressive disorder. For example, Ghaemi and colleagues found that bipolar disorder was misdiagnosed as unipolar depression in 37% of patients who initially sought treatment with a mental health clinician following their first manic or hypomanic episode.

Moreover, an average of 10 years elapsed between the onset of mood symptoms and accurate diagnosis of bipolar disorder. Why is bipolar depression so difficult to diagnose? First, hypomanic and even manic episodes may go unreported by patients.

Second, more than 50% of patients with bipolar disorder experience a depressive episode as their first mood episode. Third, although atypical depressive symptoms (eg, hyperphagia, hypersomnia, profound fatigue, and psychomotor retardation) may occur more commonly in bipolar depression, they are not pathognomic symptoms for bipolar depression and can occur in unipolar depression as well. Fourth, the diagnosis of bipolar II disorder, bipolar disorder NOS, and cyclothymia can be difficult to diagnose because the brief and relatively mild excursions into hypomania may be difficult for patients to recall or characterize as abnormal, and therefore difficult for clinicians to elicit.

Ok so quick DSM IV summary of bipolar II:

1. Presence (or history) of one or more Major Depressive Episodes.
2. Presence (or history) of at least one Hypomanic Episode.
3. There has never been a Manic Episode or a Mixed Episode.
4. The mood episodes in Criteria A and B are not better accounted for by Schizoaffective Disorder and is not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.
5. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
   

What is the DSM IV?

Psychiatric diagnoses are categorized by the Diagnostic and Statistical Manual of Mental Disorders, 4th. Edition. Better known as the DSM-IV, the manual is published by the American Psychiatric Association and covers all mental health disorders for both children and adults. It also lists known causes of these disorders, statistics in terms of gender, age at onset, and prognosis as well as some research concerning the optimal treatment approaches.

Mental health professionals such as psychologists and psychiatrists use this manual when working with patients in order to better understand their illness and potential treatment and to help 3rd party payers (e.g., insurance) understand the needs of the patient. The book is typically considered the ‘bible’ for any professional who makes psychiatric diagnoses in the United States and many other countries.

The DSM uses a multiaxial or multidimensional approach to diagnosing because rarely do other factors in a person's life not impact their mental health. It assesses five dimensions as described below:

Axis I: Clinical Syndromes

This is what we typically think of as the diagnosis (e.g., depression, schizophrenia, social phobia)

Axis II: Developmental Disorders and Personality Disorders

Developmental disorders include autism and intellectual disabilities, disorders which are typically first evident in childhood

Personality disorders are clinical syndromes which have a more long lasting symptoms and encompass the individual's way of interacting with the world. They include Paranoid, Antisocial, and Borderline Personality Disorders.

Axis III: Physical Conditions which play a role in the development, continuance, or exacerbation of Axis I and II Disorders

Physical conditions such as brain injury or HIV/AIDS that can result in symptoms of mental illness are included here.

Axis IV: Severity of Psychosocial Stressors

Events in a persons life, such as death of a loved one, starting a new job, college, unemployment, and even marriage can impact the disorders listed in Axis I and II. These events are both listed and rated for this axis.

Axis V: Highest Level of Functioning

On the final axis, the clinician rates the person's level of functioning both at the present time and the highest level within the previous year. This helps the clinician understand how the above four axes are affecting the person and what type of changes could be expected.