Depression and Bipolar info explaining the latest research in everyday English


When to suspect bipolar disorder

The Journal of Family Practice has a useful practitioner’s guide to identifying when a patient may be presenting with bipolar disorder symptoms.

As the authors say, bipolar disease is often misdiagnosed, sometimes repeatedly.

The authors—Muruga Loganathan, MD, Kavita Lohano, MD, R. Jeanie Roberts, MD, Yonglin Gao, MD, and Rif S. El-Mallakh, MD—report that close to one-third of patients with bipolar disorder seek medical care within a year of the onset of symptoms, but nearly 70% do not receive an accurate diagnosis until they’ve seen four physicians.

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) defines 4 types of bipolar illness: bipolar I, bipolar II, cyclothymia (the most mild form), and not otherwise specified The key feature of all 4 types—and the distinguishing characteristic that diagnosis typically hinges on—is a manic or hypomanic episode.

Although a full-blown manic episode may not be hard to identify, hypomania is easily missed. By definition, hypomania—with its heightened sense of well-being and productivity—is not problematic and is rarely a patient’s primary complaint.

Mixed mania, a feature of bipolar I, is the worst of both worlds: It is a state in which a full manic episode is superimposed on a full depressive episode—a depression with all the energy and force of a mania. Patients who have experienced one episode of mixed mania have a 12-fold increase in mixed states, 6.5 times more depression, and 1.7 times more dysthymia than those who experience manic episodes without the overlay of depression.

I and countless others can attest as to how horrible it is.

The authors recommend using the Mood Disorder Questionnaire (MDQ) constructed by Hirschfeld et al. as a useful guide to bipolar disorder identification. There’s a copy of the MDQ in the JFP’s article, as well as the original source article.

If you or someone you know is wondering if they might have bipolar disorder (and one psychiatrist I know of is convinced that all ‘depressive’ patients have an element of mania within their history and should therefore be considered in a new, bipolar, light) then ask their GP to administer the MDQ, or refer them to someone who can.

It could be the help they need to get them on the path to managing their illness appropriately.


Hirschfeld RM, Williams JB, Spitzer RL, et al. Development and validation of a screening instrument for bipolar spectrum disorder: the Mood Disorder Questionnaire. Am J Psychiatry.

Loganathan, Muruga; Lohano, Kavita; Roberts, R. Jeanie; Yonglin Gao; El-Mallakh, Rif S.  When to suspect bipolar disorder. Journal of Family Practice, Dec2010, Vol. 59 Issue 12, p682-688, 7p

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Letter to my psychiatrist: 7th Sept 2009

G’day D,

I’m due to see you next week, but I’ll be in Sydney on that day so I guess I won’t see you until the appointment in October.

I think we need to look at a different drug regimen – perhaps the Efexor is losing its efficacy with me. I certainly feel like I’m unravelling at a faster and faster rate.

Just today I have deliberately and successfully over-priced my services on a quote in order to not get the work. Normally I would have jumped at the chance to earn $15-20k for a month or so of work, but I can’t even complete the simple tasks I have at the moment, let alone entertain the prospect of taking on more responsibilities.

The escapist fantasies still loom large in my thoughts and I wonder if I am bringing them to fruition with my own behaviour – all I want to do is expire, to have my light extinguish itself peacefully; to suffer a cardiac arrest from which I do not recover, an infection from a superbug from which there is no cure.

I feel like I am sliding down an ever-increasing spiral, the speed picking up and the wind blowing in my hair as I dissemble, deteriorate and hopefully die.

Naturally, being the skilled showman I am, I can smile and laugh and cause merriment in others. But each day finds me sadder and sadder, each night a torture as I smile for my wife and try not to scare her.

As a pop song in the mid-late 1990s had it, “the drugs don’t work.” Not at the moment, at any rate.



On depression, anxiety, and 40 days and nights

A Second Life avatar relaxing at the beach

One of the thoughts that crossed my mind during the week was how we rarely if ever take a break.

I’m not talking about holidays – although most of us don’t take our full allotment of holidays in one go, and when we do we invariably fill those days with adventure, excitement and stimulation.

No, I’m talking about the ‘40 days in the wilderness’ stuff, the retreat (religious or otherwise) that allows us to go somewhere quiet and do little else except recharge our thoroughly depleted batteries and spend days and nights in quiet alcohol-free contemplation.

There are so many competing demands on our time, even away from the hurly-burly of work, that the opportunity to escape for any period longer that a long-weekend is sadly not an option for the vast majority of us.

Yet how different might our mental health be if we allowed ourselves the luxury (and it IS a luxury) of unplugging from the world for two or more weeks whilst still having our basic needs of food, shelter and personal safety met? How less anxious might we become? How less stressed might we return?

Perhaps only those who are stressed, depressed or anxious might understand the need to ‘disappear’ from view for a little while… our already over-worked families and friends would, I’m sure, be less than impressed by our desire to unhitch ourselves from our responsibilities and dump even more of a load on them. I can’t say I blame them.

But in an ideal world wouldn’t it be lovely to have the freedom to be able to leave all one’s worldly cares and possessions behind and disappear for ‘forty days and forty nights’ in order to face one’s demons and peer into the murky depths of one’s own black soul?

With thanks to Drinda for the inspiration behind this post.

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Does caffeine and kids equal depression?

Caffeine use among children and adolescents may have harmful effects, including depression.

Caffeine is the only legal psychoactive drug that everyone can use. Teens and pre-teens are regular drinkers of drinks such as Diet Coke, Mountain Dew, Pepsi, and other pre-packaged coffee drinks. Anyone in the vicinity of cafes will also notice a number of teenagers regularly having a fresh-brew coffee before or after school.

But research just published by the American School Health Association shows strong negative outcomes when youth drink caffeine, and the younger they are the stronger the psychological effect.

One hundred and thirty five 5th graders and 79 teenagers were studied for their caffeine use, and both groups showed frequent caffeine use. Worryingly, both groups were more likely to self-report depressive symptoms the more caffeine they ingested.

There didn't appear to be any impact on 'anxiety' with increased caffeine use, but certainly there are strong effects on depression, which impacts on the student's sleep patterns and academic and social performance.

The authors certainly recognise limits with their study, which are important but not massively so, and end their paper with two suggestions:

  1. That direct education about the risks of over-indulgence with caffeine (and what are 'safe levels) would be beneficial; and
  2. That research be conducted on the effect of caffeine on not only depression and anxiety, but also sleep, academic performance, social functioning and social interaction with peers and adults.

I don't know about teenagers (it's a long time since I was one), but the paper certainly makes me question whether the large amount of fresh-brew coffee I take daily is doing my mental health any good...

Source: Luebbe, A.M., & Bell, D.J. 2009. Mountain Dew or Mountain Don't?: A pilot investigation of caffeine use parameters and relations to depression and anxiety symptoms in 5th- and 10th-grade students. Journal of School Health, 79(8); 380-387

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Do SSRIs erode your bones?

There's a growing body of evidence that SSRIs are eroding bones, resulting in increased risks of osteoporosis and fractures.

The Harvard Mental Health Letter for August 2009 reports on a ten-year history of research that noticed a disturbing correlation (a seeming relationship between two sets of data): depressed patients had lower bone strength and a greater risk of fractures.

Although the earlier studies left the door open to a pharmaceutical reason for increased risk of fracture (as in, the medications used may have caused dizziness, resulting in falls and fractured bones), later studies have been better-designed and seem to implicate SSRIs are causing bone erosion.

Two recent significant studies appear to conflict. One finds that inhibiting 5-HTT, which SSRIs do better than any other antidepressants, slows bone formation and accelerates bone resorption (which is when calcium and other minerals are released into the bloodstream, leaving trenches behind in the bones); the other finds that inhibiting 5-HTT actually increases bone mass.

5-HTT is the transporter mechanism for 5-HT, which you might know as serotonin; SSRIs enhance serotonin activity.

Despite the conflict between the two aforementioned studies, the Canadian Multicentre Osteoporosis Study Research Group followed 5,008 men and women who were aged 50 and over for five years, finding that the patients who were taking SSRIs everyday had lowered bone mineral density measurements, particularly in the hip. They were also twice as likely as non-SSRI-taking patients to suffer a bone fracture.

Ways to overcome any risk of bone erosion include increasing the intake of calcium, increasing the intake of vitamin D, reducing the amount of caffeine and alcohol taken, and exercising in a way that bears weight on bones (such as walking, weight lifting, stair climbing). It also seems that some medications help slow bone resorption: alendronate (Fosamax), risedronate (Actonel) and ibandronate (Boniva) are mentioned positively.

Of equal significance is that no one has yet taken a look at how SSRIs might affect the bones of children or teenagers.

Source: Harvard Mental Health Letter, August 2009 -

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Does depression and lowered self-esteem affect how safe you feel your neighbourhood is?

Depression, lowered self-esteem, perceived neighborhood fear and drug use among young adults.

We all know that some neighbourhoods feel 'riskier' than others -- somewhere not to walk alone at night, somewhere not to engage with groups of local youths -- but is our level of self-esteem and depression a confounding factor? Do we take more drugs if we are depressed and/or suffering low self-esteem, and if so do we then rate our neighbourhood as 'riskier'?

These are the questions that Katherine Theall, Claire Sterk and Kirk Elifson sought to answer with a four-year study in Atlanta, Georgia, USA.

We know from the academic literature that stress, and exposure to stressful situations, is not good for our health, including reduced immune defences and increased risk of depression. Additionally, social stress (such as being scared to walk in your neighbourhood for fear of violence or victimisation) can lead to feelings of helplessness and hopelessness, often (but not always) leading to escapist activities such as drug use, alcoholism, and increased sexual risk-taking behaviour as examples.

Research has shown that depressed individuals (regardless of their environment/neighbourhood) are more likely to initiate drug use, or relapse back to drug use, as well as indulge in greater levels of risk-taking behaviour, sexual and alcohol-associated included.

Theall, Sterk and Elifson sampled 210 inner-city young adults (18-25 years of age) who were recruited from Atlanta between September 2002 and August 2006. Interestingly, according to records from the Atlanta Police Department and the Community Epidemiology Work Group of the National Institute on Drug Abuse for Atlanta showed no major shift in crime or drug trends over the study period. That isn't to say that crime and drug use didn't change, only that the official records didn't capture any significant changes.

They found that the strongest predictors for perceived fear of one's neighbourhood include being unemployed, being a gang member, being physically or sexually abused, suffering low self-esteem and suffering from depressive symptoms.

What they were really looking for they didn't find: while increased fear did result in increased drug use, these behaviours did not appear to be as a result of lowered self-esteem or increased levels of depression.

The implication of the study seems to be that lowered self-esteem or higher levels of depression by themselves have no significant effect on how likely someone is to take drugs in order to 'cope' with their fear of their neighbourhood. It would appear that more inclusive factors -- such as a person's household, community and personal resources -- as well as sociological-level interactions need to be taken into account when considering how to reduce the 'fear factor' a certain neighbourhood might raise in a neighbourhood resident.

Source: Theall, K.P., Sterk, C. E., & Elifson, K.W. 2009. Perceived neighborhood fear and drug use among young adults. American Journal of Health Behavior; 33(4): 353-365

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Depression, infertility and psychological interventions

By adding in psychological interventions BEFORE early assisted reproductive technology (ART) treatment the chances of infertile women becoming pregnant increase significantly; at least Fertility Weekly - July 6 & 13, 2009 reports.

Katja Haemmerli and colleagues in Switzerland conducted a meta-analysis of 384 articles published between 1978 and 2007 and concluded that early-stage psychological intervention to help treat those women who weren't receiving medical intervention could not only treat mental distress, anxiety and depression, but also aid their chances of becoming pregnant.

Definitely worth following up with your doctor if you are finding a challenge in becoming pregnant and starting to becoming anxious or despairing...

Source: Hammerli et al, 2009. The efficacy of psychological interventions for infertile patients: A meta-analysis examining mental health and pregnancy rate. Hum Rep Update; 15(3): 279-295

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“Get me off this merry go round”: Barriers to treatment of depression in some adolescent mothers

It came as a shock to me to read that about 500,000 adolescent girls give birth each year in the United States, many of them suffering low levels of income and additionally not covered by private health care insurance.

Very often, it seems, treatment for post-natal depression can be hampered by the new mother's inability to disclose feelings and lack of knowledge about post-natal depression.

According to various studies, adolescents who aren't recent child-bearing have reported many barriers to treatment for depression:

  • a lack of knowledge about where to obtain help;
  • a feeling of stigma about having a mental health disorder and a fear of that being disclosed to peers;
  • a concern that their parents will be notified of their health disorder and the teenagers don't want their parents to know;
  • a lack of transport opportunities to get them to treatment facilities (meaning they may have to ask their parents, and thus be forced to explain what the appointment is for and why they need it);
  • a lack of assistance from their family -- some parents decide that their children don't have a mental health disorder (or are fearful of the inter/intra family, cultural and community stigmas that surround mental health issues) and so where possible do not assist in any treatment and even cancel treatment plans and schedules;
  • prior use of mental health services by the adolescents.

However, no such research into treatment barriers had been conducted on adolescent mothers.

The authors worked with nine teen parents, average age 16 years and racially mixed: four African American, two Caucasian, two Hispanic and one Native American.

Interestingly, none of the mothers used the words "depression" or "postpartum depression"; instead they used words like "crying," "sadness," "anxiety," and "frustration." They also talked about sometimes not having any interest in activities or the baby, not wanting to do anything for themselves, lacking in patience and not being able to put up with everything they have to cope with.

Readily admitting that the tiny sample size and only using one geographic area hampered the 'generalizability' of the results, plus a lack of non-depressed new mothers in the study to act as a possible 'control' group, the authors still reported some interesting findings and make some useful suggestions:

  • finding: the mothers were far more likely to seek help from their boyfriend, mother, sister or other family member before seeking the help of health professionals;
  • finding: additional to the point above, they were more likely to consider going to church and praying, writing their feelings down, getting some sleep, and playing with the baby before seeking professional help;
  • finding: the new mothers were very unprepared for the time-intensive nature of mothering, especially when the child is ill;
  • suggestion: school-based teen parenting programs should include more information on depression, how to recognise it and what to do about it;
  • suggestion: maternal-infant relationship programs should be assessed and introduced into teen parenting programs.

One of the challenges of depression is that it reduces cognitive ability, including language skills -- it becomes harder and harder to express one's feelings, even to identify them accurately, and so seeking professional help is less and less likely to figure in anyone's self-defence repertoire.

When you add in a lack of knowledge about post-natal depression, combined with lack of resource (community support, money, significant suppportive relationships, as examples) and a lack of belief in their ability to cope with a new baby (teens seem to have less belief in their ability to cope than adults, according to one of the study's authors), you have a cocktail of negative influences that can work against the already-stressed new mother.

This study at least helps to identify some of those influences and suggest ways to overcome them.


Source: Logsdon, M. Cynthia, Hines-Martin, Vicki and Rakestraw, Vivian (2009) 'Barriers to Depression Treatment in Low-Income, Unmarried, Adolescent Mothers in a Southern, Urban Area of the United States', Issues in Mental Health Nursing, 30:7, 451-455

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Is a history of depression likely to lead to dementia?

A team of researchers has looked at three questions:

  1. Whether a history of depression is associated with an increased likelihood of dementia,
  2. Whether a first depressive episode earlier in life is associated with increased dementia risk,
  3. Whether only depressive episodes close in time to dementia onset are related to dementia.

The team looked at depression information from national hospital discharge registries, medical history and medical records, and the dementia had to be clinically diagnosed.

It turns out that there is no link between early depressive episodes and dementia; indeed, they found that each 1-year increase between the onset of depression and the onset of dementia reduced the likelihood of dementia by 8.4%.

However, all is not rosy: there is definitely a relationship between dementia and depression (and this relationship has a long history in academic research). In twin studies they found that twins with prior depression were three times more likely to have dementia than their non-depressed twin.Whilst a depression that first started more than 10 years prior to the onset of dementia is not associated with an increased likelihood of dementia, any depression that was first diagnosed within 10 years of dementia onset was associated with nearly 4 times the likelihood of having dementia, and more than 2.5 times the likelihood of the sufferer going on to develop Alzheimers.

The implication of these findings is that rather than late-life depression being a risk factor for dementia, it may well be an early-warning symptom that dementia or Alzheimers is about to occur.

As for me, it is a relief to know that my long history of depression is not an automatic jail sentence in the prison of dementia.

Brommelhoff, J. A., Gatz, M., Johansson, B., McArdle, J. J., Fratiglioni, L., & Pedersen, N. L. (2009). Depression as a Risk Factor or Prodromal Feature for Dementia? Findings in a Population-Based Sample of Swedish Twins. Psychology and Aging, 24, 2, 373-384

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Anxiety and depression in older adults: a link with cognitive performance?

Is there a relationship between anxiety, depression and cognitive processes in the elderly?

This was a research question that occupied Sherry A. Beaudreau and Ruth O'Hara from Stanford University School of Medicine and the Sierra Pacific Mental Illness, Research, Education and Clinical Center (MIRECC) at the Veterans Affairs Palo Alto Health Care System.

Unfortunately, the answer is the classic, "it depends."

They found that if you take 'anxiety' out of the patient, but keep 'depression' in, you get no difference in cognitive processing -- suggesting that depression itself is not a major contributor to reduced mental performance.

But if you have an anxious elderly adult, either with or without depression, you will also have someone whose mental performance is reduced.

Personally, I'm not sure that you can totally separate 'anxiety' from 'depression' -- my personal experience is that anxiety is nearly always a component of depression, or at least a close travelling companion.

To be fair to Beaudreau and O'Hara, they do note that their sample of 102 community-dwelling older adults were well-educated and also self-reported a mild, not major, state of depression. Had the sample been taken from a population under the care of psychiatrists, it may well have shown similar results to previous studies of such patients and reported impairment of memory and a reduced ability to rapidly shift attention (Beaudreau and O'Hara cite studies from Butters et al., 2004 and Mantella et al., 2007 for those interested in finding out more).

Perhaps the 'take away' from the research is that if you are responsible for or have an elderly relative yourself who is reporting mild depression (which the vast majority of the elderly do), and you witness a slowdown or impairment in their mental faculties that cannot be considered part of 'dementia' or Alzheimers, then have a look at what if any anxiety-producing stressors they have in their environment, or in their inner-world.

Helping to reduce their anxiety, whilst still acknowledging and accepting their depression, may go some way to helping them restore their mental performance.


Beaudreau, S.A., & O'Hara, R. (2009). The Association of Anxiety and Depressive Symptoms With Cognitive Performance in Community-Dwelling Older Adults. Psychology and Aging, 24, 2, 507-512

also referenced:
Butters, M. A., Whyte, E. M., Nebes, R. D., Begley, A. E., Dew, M. A., Mulsant, B. H., et al. (2004). The nature and determinants of neuropsychological functioning in late-life depression. Archives of General Psychiatry,61, 587-595.

Mantella, R., Butters, M. A., Dew, M. A., Mulsant, B. H., Begley, A. E., Tracey, B., et al. (2007). Cognitive impairment in late-life generalized anxiety disorder. American Journal of Geriatric Psychiatry, 15, 1-7.

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