One example of how this may manifest is as follows: You may notice the person isn’t quite right for some period of time. They may have mild depression or be irritable or overly suspicious of others raising concerns about their mental health. Since the problem comes and goes, no one may say much about it. The person may feel like they are losing control or feels depressed, but also may not say much to others about it. Then it seems things build and the person has a “break down” with more obvious depressed, manic or psychotic symptoms.

A person may have a prodromal period lasting months to years. We often see prodromes in illnesses such as bipolar disorder and schizophrenia. Since the incidence of these illnesses peak in early 20’s for males and late 20’s for females, the prodrome may be seen as early as late teens or early 20’s. Studies show early medical intervention during this period can make a big difference in the course of the person’s illness.

More recently researchers have found Provigil to be helpful in treating bipolar disorder patients who were depressed. Two studies in the August 2007 issue of the American Journal of Psychiatry (164: 1242 -1249 and 164: 1143 -1145) show some benefit to bipolar depressed patients when they were treated with 100-200 mg of Provigil.

These are preliminary results, but this is very promising and could be huge for the treatment of bipolar disorder. It is not uncommon for patients with bipolar disorder to have their mania managed with mood stabilizers but still bottom out on the depressed end. What’s even more positive are the findings that Provigil did not significantly increase a person’s risk of developing mania.

Other studies show that 28% – 38% of those with bipolar disorder have a separate anxiety disorder. One study in the American Journal of Psychiatry (2004;161:2222-9) showed that an anxiety disorder occurring with bipolar disorder was associated with an earlier age of onset. The authors noted that teenagers developing bipolar disorder at an earlier age likely began with anxiety problems as a prelude to developing the mood symptoms.

Why is this important? Unfortunately we have seen that anxiety disorders can worsen the course of depression or bipolar disorder, making it harder to achieve remission of symptoms. The untreated symptoms can lead to substance abuse as a way to self-medicate. If a person is in the throws of serious mood episode (depression or mania), it can be easy for all those involved to overlook the anxiety disorder or not aggressively manage the anxiety because of the attention to the mood symptoms. So these findings emphasize the importance of diagnosing and managing comorbid anxiety disorders in individuals with major depression or bipolar disorder.

At the International Conference on Bipolar Disorder, Dr. Rasmus Licht of Denmark reported on a study of 155 adult patients with bipolar disorder. The patients were treated with lithium and lamotragine (lamictal). They found lamictal tended to be more effective in patients whose index episode was depression and lithium was better for patients whose index episode was mania.

Unfortunately, they found that by five years on the single medication, only two out of the original 155 patients were able to remain on one medication. The remaining patients failed treatment (had a relapse of symptoms) and this usually happened within the first 1 1/2 years.

Following bipolar patient’s progress for five years makes this study unique, and it supports the idea that the majority of patients require more than one medication to control their symptoms in the long run.

Bipolar disorder or manic depression is a mood disorder whereby a person has discreet episodes of depression or mania. The index episode is a term used to define the first episode. If a person’s index episode is depression, they may not be diagnosed with bipolar disorder until they have a manic episode. That is, this person may be diagnosed as having depression for years until they have a manic episode at which time their diagnosis will change to bipolar disorder. The person who has mania as their index episode will start with a diagnosis of bipolar disorder.

Everyone is different, but a typical course of the illness is such that a person may have 1-2 episodes of mania and/or depression in a year or every few years. Rapid cycling bipolar disorder is defined by having four or more episodes in a year.

So back to the question – people with bipolar disorder don’t switch between depression and mania within the course of a day. In fact, depression requires symptoms lasting two weeks to be considered a depressive episode. The situation of extreme moods that flip back and forth over the course of a day would be considered emotional lability or emotional volatility that may be present in a person with anxiety or a mood disorder (such as depression or bipolar disorder). But it can also be a part of someone’s personality. For example, people with histrionic personality traits can have dramatic or “over the top” responses that are intense reactions to life issues that are not necessarily a mental disorder that requires medication treatment.