Anxiety Worsens Depression and Bipolar Disorder

A symptom of depression can be anxiety, but a person can also have a co-morbid (meaning simultaneously occurring) anxiety disorder that is a separate entity from their depression. Some anxiety disorders that can occur with depression are Panic Disorder, Generalized Anxiety Disorder, Obsessive Compulsive Disorder, Social Phobia and Post-Traumatic Stress Disorder. It is not uncommon for the anxiety to present prior to the depression. In fact, according to an article in the Journal of Psychiatric Research (2003;37:187-92), the prevalence of generalized anxiety occurring with major depression is close to 70%. This is a high percentage.

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.

Multiple Medications Common in 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.

Not All Mood Swings are Bipolar Disorder

I sometimes hear people ask “one minute I feel down, the next minute I’m really happy, am I manic depressive?”

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.

Is it me or my illness?

Individuals with an disorder such as bipolar disorder can behave in ways that make them question whether their actions are part of their personality or part of their illness.  For example, two common symptoms with bipolar disorder are hypersexuality and hyperreligiousity.  However, defining what is “hyper” is not always an easy task.  It can be very difficult to tease out what is the person’s personality and what is being driven by the disinhibition that you can see with a manic episode.  It is often during a euthymic period (neither manic nor depressed) that a person can do some introspection and get a sense of who they are.  It can be sobering for some to realize their free spiritedness, high sex drive, etc. may have been their illness.  They are then left to figure out who they really are.

In a similar way, chronic irritability that may seem a part of someone’s personality could be persistent depression that once treated significantly improves.  In these cases, a person may feel relief to know they are capable of feeling happy or having a good outlook on life.

Am I Depressed or Just Not Manic?

Sometimes it’s difficult for bipolar patients to tell when they are in a depressed mode or if they have simply lost their manic high.  For many, mania can be a very destructive phase, but for some, mania or hypomania (milder form of mania) can feel very good and be a very productive time.  Sometimes this loss of the elation can make patients not want to take their mood stabilizer.  Some will say they experience the non-manic period as being flat or as if they are living a generic version of themselves.  They may then conclude they are “depressed” when in fact, they may not be depressed, they are just experiencing the middle ground.

Some patients may swing between cycles so often that they may not know how to recognize the middle ground.  This is why it is important for patients with bipolar disorder to stay in regular contact with their health care provider so they can have someone keeping an eye out for their mood states.  It’s not always as easy to recognize the beginning of a manic state as it is to recognize depression.  A person who is hypomanic may appear happy, upbeat and busy.  On the surface, that doesn’t seem so bad.  But it is usually the people close to them that recognize the more destructive behaviors such as functioning on little sleep, making impulsive decisions, etc.  So, although the hypomanic state may seem desireable and some even try to prolong the state (by avoiding medication), mania can spiral out of control.  Therefore it is important to keep a careful watch and welcome periods of non-mania and middle ground.