A common misperception among some clinicians and patients is to think of 'depression' as being equivalent to unipolar depression, which is then treated with antidepressants. There are a number of reasons for this phenomenon: the first is that patients often lack insight into their manic symptoms; not knowing that they are ill, they deny their manic symptoms to clinicians. Second, depressive symptoms tend to last longer than manic symptoms, sometimes are more frequent, and often are more psychically painful; thus, patients tend to seek assistance when depressed rather than when manic. Third, the many new antidepressants that have become available over the past 10 years have been extensively marketed to physicians at the same time that 'depression awareness' programmes have educated the public about the availability of safe and effective treatments. Simultaneously, few new treatments for bipolar disorder have become available, and there has been scant professional and public education about bipolar illness. For example, the mainstay of bipolar treatment, lithium, is an inexpensive generic drug with minimal funds available for its promotion or for educational efforts.
As with the differential diagnostic process in any medical disease, the diagnosis of mood disorders should start with those disorders that must be ruled out first to those that remain afterwards (Fig, 3). We believe that this process should begin by ruling out depression which is clearly due to another medical or psychiatric disorder, or substance abuse. Such 'secondary depressions' usually involve a single major episode occurring in the absence of prior depressive symptoms or family history, and at a later age of onset than is typical for primary depression. The second rule-out diagnosis is bipolar disorder: first, bipolar I, then bipolar II, and next bipolar 'not otherwise specified' should be sequentially ruled out before unipolar depression can be diagnosed. Unfortunately, many clinicians and patients jump from the recognition of a major depressive syndrome directly to a diagnosis of unipolar depression without the critical intermediate process of ruling out bipolar conditions. The relevance of this process lies in the underappreciated fact that antidepressants can worsen bipolar illness, either by causing acute mania or by acting as mood destabilizers, counteracting the effects of mood stabilizers, and leading to a long-term rapid-cycling course of illness. (29>
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Fig. 3 The differential diagnosis of mood disorders: moving from 'depression' to diagnosis. The order in which diagnoses need to be excluded is as follows: (1) secondary depression; (2) bipolar depression; (3) unipolar depression. Thus, unipolar depression is a diagnosis of exclusion.
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Are You Depressed? Heard the horror stories about anti-depressants and how they can just make things worse? Are you sick of being over medicated, glazed over and too fat from taking too many happy pills? Do you hate the dry mouth, the mania and mood swings and sleep disturbances that can come with taking a prescribed mood elevator?