From The Quarterly, January 2016
Robert M.A. Hirschfeld, M.D., is a professor of clinical psychiatry at Weill Cornell Medical College. Prior to joining Weill Cornell in April 2015, he served for nearly 25 years as Professor and Chair of the Department of Psychiatry at the University of Texas Medical Branch in Galveston; and for 18 years at the National Institute of Mental Health as Chief of the Mood, Anxiety, and Personality Disorders Research Branch. He is a founding member of the Foundation’s Scientific Council, a 2002 Distinguished Investigator grantee, and winner of the Falcone Prize for Outstanding Achievement in Affective Disorders Research (renamed the Colvin Prize in 2012).
Dr. Hirschfeld is world renowned for his research on the diagnosis and treatment of bipolar disorder and depression. He developed the Mood Disorder Questionnaire (MDQ) in 2000, the most widely used screening instrument for bipolar disorder in the world. He served as chair of the original and the revised American Psychiatric Association Guidelines for Treatment of Patients with Bipolar Disorders.
There are lots of misconceptions about bipolar disorder. Can you define the disorder and explain the relation between its “manic” and “depressive” phases?
Bipolar illness was once referred to as “manic-depressive” illness. It’s usually a lifelong disorder, characterized by episodes of abnormal, often persistent, highs, and abnormal, often persistent, lows. The highs are characterized by a “too good” mood, irritability, increased energy, increased interest in activities, decreased need for sleep, and sometimes, delusions— some people who are manic actually believe they can fly or believe they have super powers.
Sometimes, people who are in the “manic” phase of bipolar disorder make rash decisions, do things that get them into trouble, such as spending way too much money, or getting involved in sexual promiscuity—this would be in people who would never, when not manic, be promiscuous—and it’s all part of the illness. Of course, behaviors of this kind can ruin lives, families, and relationships.
The other half of the illness involves depression, which is almost the polar opposite of mania. You have decreased energy, lower mood, you’re sad—you feel empty, depressed. You’re very pessimistic—you only see the negative side of things. And, of course, there is always a possibility of suicide, when people are depressed in this way.
I want to make sure I understand the relation between the two phases, manic and depressive. If I hear you right, they’re both features of bipolar illness, but the “high” itself has nothing to do with a crash that must follow next. The up and down phases don’t cause one another or necessarily follow in sequence.
That’s mostly correct. You don’t need the depression to make the diagnosis; you do need at least one manic or hypomanic [a less severe form of mania] episode. But in general I would characterize bipolar disorder as an illness usually involving episodes of both highs and lows.
Is it hard to determine if a person has bipolar disorder, since we all have highs and lows? Statistics show that only about three percent of us have bipolar disorder.
It’s true that everyone on the planet, or almost everyone, has times when they’re feeling good, when they have a lot of energy, like when new projects are coming up, that kind of thing. But it’s different in those with bipolar disorder. Their ups are different from those that healthy people have. One symptom that’s characteristic is that the need for sleep decreases substantially in people with mania. People who normally sleep eight hours a night to feel rested are sleeping four or five hours, and are waking up in the morning with complete energy. People in the depressed phase of the illness can sleep for 12 hours, and still have no energy. Those lows are different than the usual lows that virtually everyone has.
In fact, the latest edition of the manual that doctors use to diagnose psychiatric disorders, the DSM-5, has made a major change in how we conceptualize and diagnose bipolar disorder, one that I think is very helpful—and that is to include not just the mood disturbance that we’ve been talking about, but also the disturbance in energy, and in activation. We’ve always seen this as part of the illness. But now it’s understood as a necessary part—if you simply have the mood disturbance and no change in energy, you do not get a diagnosis of bipolar disorder.
What is the difference between the two major types of bipolar disorder, called “Bipolar I” and “Bipolar II?”
Bipolar I is the more classic form of the disorder which requires at least one episode of mania. People with Bipolar I can have episodes of less severe hypomania (see below), but must have at least one manic episode.
Bipolar II involves at least one episode of hypomania. Hypomania is less severe than mania and does not require hospitalization or include delusions. But let me stress that Bipolar II is not necessarily a less severe illness, because the depressions that can occur in both types—Bipolar I and II—can be equally severe. Hence, there is an elevated suicide risk in both types.
The rate of suicide is quite elevated in people who have the diagnosis, compared with the rate in the overall population.
True. The most frequent cause of suicide is depression, and depression is fundamental to bipolar disorder. The elevated suicide rate among people with the illness is almost exclusively related to the “depressive” phase, not the manic.
We sometimes hear of “rapid cycling” or the “rate of cycling.” What does this mean?
Rapid cycling refers to having frequent episodes—four or more in a year. It’s more common to have one or two episodes in a year. Those who have frequent episodes are often more difficult to treat. In fact, there are people who cycle even more rapidly, on a two- to three-day cycle. There is disagreement about how to classify such patients, but I certainly treat people who have cycles as short as a single day in length. They are clearly hypomanic for that day, and then depressed the next day.
When you say “episodes,” do you mean both the “up” and “down” phases—together they make one episode?
No. Either one is an episode. You can have manic-only cycles or depressed-only cycles. You don’t have to cycle back and forth. Some people will become manic for a very short period of time, then they return to normal mood; and their next episode could again be manic, or it could be depressive.
When someone is depressed, how do you know if they are “just” depressed—what doctors call “unipolar depression”—or perhaps they are in the depressive phase of bipolar disorder?
The issue of missing bipolar disorder is one that I’ve done a lot of research on and have been concerned about for my entire professional life. The problem is that most bipolar patients first come in depressed. About about one in five depressions we see—20 percent—are people who in fact have bipolar disorder. That’s a lot.
One problem is that people don’t think about the possibility of bipolar illness. The patient coming in with depression may not even remember that they’ve had hypomanic or manic episodes, and they don’t bring it up. The family isn’t thinking about it. And if the healthcare provider doesn’t ask, it’s missed. I’ve done a number of studies on this. It’s really easy to miss. Someone comes in, and they’re so low that they almost crawl into your office—you can’t imagine this person being high, being manic. But they may have been, and so if you don’t ask about it, you’re not going to find out about it. I like to have a family member come in with the patient on the first visit because they can often bring very useful information that the patient him or herself is just not able to get in touch with.
How many bipolar patients lack insight about their condition, for instance, have no self-awareness of having been manic?
In Bipolar I, it’s probably 40 to 50 percent—a substantial number. In Bipolar II, [it’s] substantially less. In general, those with Bipolar II don’t have the devastation to family, career, and education in the same kind of way. But they do have terrible problems with productivity, lost jobs and so on, because they have been depressed and they can’t deliver on things one is expected to do in life.
In Bipolar I, the most common variety, it usually takes several manic episodes, having devastating consequence, before people with the disorder recognize they actually have an illness and they’re going to have to deal with it for the rest of their life. They will deny, deny, deny—and it’s very sad. I often see people in their 30s who are finally coming to terms with it and they have lost a decade of their life to the illness.
Is there any way to prevent this tumult?
The problem of self-awareness is real and is one of the reasons we developed the MDQ—the Mood Disorder Questionnaire. It’s a 13-question “yes/no” questionnaire, asking things about whether you’ve ever had times when you spent too much money, times when you had an abnormally high mood—it goes through a number of the symptoms of mania, and it takes about five minutes to fill out. You can score it, or a health professional can. It’s available on the Internet if you do a Google search. You can also get it in many doctors’ offices, and certainly from advocacy organizations. (The MDQ is available at www.dbsalliance.org/pdfs/MDQ.pdf)
What should you do after you complete the MDQ?
Let me state again that the MDQ is a screening instrument. If you screen positively, it does not mean you have bipolar disorder. It means that you’re likely to have it and that you should be more comprehensively evaluated. If you score it yourself and are “positive,” then you should discuss the results with your primary care provider, or better, a psychiatrist or another mental health professional.
Can the MDQ help in those situations where, let’s say, a mother and daughter disagree on whether the daughter has had manic symptoms?
Yes. A version of the MDQ we recently tested specifically addresses this sort of problem, when children and their parents don’t agree on symptoms. A study in which I was involved, led by my colleague Dr. Karen Dineen Wagner (Foundation Scientific Council Member and 2012 Colvin Prizewinner for Outstanding Achievement in Mood Disorders Research), gave the adolescent version of the MDQ to parents about the child; but we also gave it to the adolescent him or herself, and also asked the child to fill it out again, this second time “pretending you are your best friend or someone who knows you well—from the point of view of what you think they would say about your behavior?”
Which of the three versions proved to be most accurate?
By far it was the form filled out by the parent. It was clear that the parents were much more able to accurately describe things that the doctors ended up strongly believing were correct in terms of symptoms.
I’ve heard in the past that there is a particular danger when someone with bipolar disorder is misdiagnosed as having only unipolar depression and is prescribed antidepressants. Can you explain?
We used to think that giving an antidepressant medication without a mood stabilizer to a patient with bipolar disorder would serve to destabilize the illness—in other words, make more cycles, more rapidly, and even might precipitate a manic episode. That was based on experience mainly with the “tricyclic” class of antidepressants, for example Tofranil (imipramine). These are medications that we use very rarely these days. It turns out that these issues are usually moot when a doctor prescribes one of the modern class of antidepressants— SSRIs like Prozac, Paxil, Zoloft. It doesn’t seem that they destabilize bipolar disorder. But for reasons we don’t understand, they don’t seem to work as well as antidepressants in people with bipolar illness.
Much more generally, what advice can you offer to anyone who is curious about bipolar disorder, who may be wondering if they or a loved one is affected? What should they do?
I would ask people to recognize that bipolar disorder is a serious brain disorder and there’s a huge amount we can do to help people with this illness to manage it, to reduce or prevent episodes. I would also strongly encourage those who are concerned that they, or a loved one or friend, might have bipolar disorder, go online, find the MDQ, and if the score is positive, or if there is any question as to the result, contact a doctor or mental health professional for a thorough evaluation.