Intended for healthcare professionals

Rapid response to:

Clinical Review

Bipolar disorder

BMJ 2012; 345 doi: (Published 27 December 2012) Cite this as: BMJ 2012;345:e8508

Rapid Response:

Re: Bipolar disorder

Disguised Bipolarity

Bipolarity in disguise raises specific diagnostic and therapeutic challenges. Bipolar depression does not only differ from unipolar depression in clinical presentation; there is also a significant difference in optimum treatment. The condition is commonly misdiagnosed because of the similarities between its symptoms and
those of major depression. There is a popular misconception that manic symptom manifests first and depression follows later; such a misunderstanding has its roots in the earlier terminology of “manic depression”. It is now well recognised that depression could start in early adult life and they declare hypomania or mania at a later period.

A subset of patients diagnosed with unipolar depression in fact suffers from bipolar depression.1 Monopolar depression needs to be readily differentiated from bipolar depression because the inappropriate use of antidepressants may precipitate a hypomanic or manic episode. Misdiagnosis can lead to unfocused treatment that may exacerbate the disease. Bipolar depression incognito differs from other forms of depression because of the high risk both of completed suicide and of psychotic features.

Atypical depressive features are more noticeable in hidden bipolar depressives, as is psychomotor retardation. 2 Bipolar depression is associated with more mood lability and a relatively acute onset. There is more cognitive blankness and emotional flatness in bipolar depression. 3 When a young person presents with psychotic depression or psychomotor retardation, bipolar depression should be ruled out. Non-specific psychological symptoms and behavioural disturbances may be the precursor of bipolar disorder in young people. 4 Any patient presenting with depressive symptomatology should be interrogated about their past history of mood elevation, and the family history of affective disorders should also be explored. Bipolar depression can occur with or without precipitating factors. Bipolar depression should be especially ruled out when depressions occur without an identifiable psychogenic stressor. Recently there has been uproar about the link between modern antidepressants and higher incidence of suicides. Most of these suicides could be due to treatment emergent hypomania in disguised bipolar depression.

In general, features of undetected/undetectable bipolarity in depression are(1) non response to antidepressants, (2)history of drug induced hypomania, (3)family history of bipolar disorder, (4)psychotic features,(5) atypical symptomatology, (7)retarded presentation, (8)postpartum onset, (9)early onset, (10) higher suicidal risk,(11) violent mood swings,(12) co-morbid anxieties,(13)past history of mood elevation,(14)isolated anti social acts and (15) legal problems. 5 Bipolar disorder is narrowly defined in DSM-IV. 6 It is also getting increasingly recognised that many of the personality disorders are larval forms of Bipolar disorder. As it can take up to ten years to confirm bipolar disorder, discovery of psycho-physiological parameters may be the solution for earlier diagnosis.

Bipolar disorder itself may be essentially a type of depressive disorder with episodic manic expression and efficient management of depression seems to hold the key to controlling and preventing the disorder. The early part of hypomanic phase could be creative and dramatic. The creative “Big bang” attributed to hypomania is short lived and is usually confined to artistic abilities, but ends up most often as a “Big crunch” if treatment is delayed.

1.Hirschfeld RM, Calabrese JR, Weissman MM(2003) Screening for bipolar disorder in the community. J.Clin Psychiatry 64: 53-59.
2.Mitchell PB, Wilhelm K, Parker G, Austin MP, Rutgers P, Malhi GS,(2001)The Clinical features of bipolar depression: a comparison with matched major depressive disorder patients. J Clinical Psychiatry 62:212-216.
3.Marneros Andreas, Goodwin Frederick (2005) Bipolar Disorders. Cambridge: Cambridge University Press.
4.Goodwin G.M (2003) Evidence-based guidelines for treating bipolar disorder: recommendations from the British Association for Psychopharmacology. Journal of Psychopharmacology 17:2149-173.
5. JP. Pandarakalam (2007) Clinical Challenges of Bipolar Depression,British Journal of Hospital Medicine Vol 68, pp234-240
6.Angst J, Azorin JM, Bwden CL, et al (2011) Undiagnosed Bipolar depression in patients with a major depressive episode. Arch Gen Psychiatry 68:792-798.

Dr. James Paul Pandarakalam,
Locum Consultant Psychiatrist,
5 Boroughs Partnership NHS Foundation Trust,
Alternative Futures Group Hospitals,
Hollins Park , Hollins Lane, Warrington WA2 8WA,

Competing interests: No competing interests

06 January 2013
James Paul Pandarakalam
Consultant psychiatrist
5 Boroughs Parnership NHS Foundation Trust.& Alternative Futures Group Hospitals.
Hollins Park Hospital, Hollins Lane, Warrington WA2 8WA