Phelps - Why Am I Still Depressed? Recognizing and Managing the Ups and Downs of Bipolar II and Soft Bipolar Disorder

Why am I still depressed?

Recognizing and Managing the Ups and Downs of Bipolar II and Soft Bipolar Disorder

Jim Phelps, M.D.

Copyright 2006 by James R. Phelps, M.D. All rights reserved. Manufactured in the United States of America. Except as permitted under the United States Copyright Act of 1976, no part of this publication may be reproduced or distributed in any form or by any means, or stored in a database or retrieval system, without the prior written permission of the publisher.

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To Anna-Maria, the fixed foot of my compass

PART I
Do You Have a "Mild" Form of Bipolar Disorder?

CHAPTER 1
Understanding the Mood Spectrum and How It Can Help You

CHAPTER 2
Can You Be a Little Bipolar? Recognizing Hypomania

CHAPTER 3
No Mania or Hypomania? Understanding "Soft" Bipolar Disorder

CHAPTER 4
Making Your Diagnosis

CHAPTER 5
What Else Could It Be? Ruling Out Conditions That Mimic Bipolar Disorder

PART II
Finding and Using the Right Treatment

CHAPTER 6
Getting Help: How You Can Work with Your Doctor

CHAPTER 7
Where to Start: Guidelines for Choosing Treatment

CHAPTER 8
Mood Stabilizers: The Core Ingredient in Medication Treatment

CHAPTER 9
What You Need to Know When Considering Antidepressants

CHAPTER 10
Managing Weight Gain from Medications or Other Causes

CHAPTER 11
Simple Lifestyle Changes That Can Improve Symptoms

CHAPTER 12
How to Use Psychotherapy Across the Mood Spectrum

CHAPTER 13
Exercise: Not the Usual Rap

CHAPTER 14
How Family and Friends Can Help

A patient told me the other day: "I don't expect to be happy; I just don't want to be depressed." We should be doing better, and part of the solution, I think, is to move away from simple-minded diagnoses and prescriptions about depression.

There is so much antidepressant use these days that Prozac is literally in the water in detectable amounts, leading to some environmental concerns regarding the effects on fish. Yet the treatment of depression is not as effective as it should be. One is tempted to recall the ironically prescient words of the nineteenth-century physician Oliver Wendell Holmes who said that "if the entire materia medica, as now used, could be sunk to the bottom of the sea, it would be all the better for mankindand all the worse for the fishes." It turns out that antidepressants are not the panacea that many once thought. One reason is that antidepressants are not always antidepressants. In some persons, like those with bipolar illness, they may not work well and in fact can make things worse.

The key issue in diagnosing and treating depression is to know what kind of depression one faces. Is it vanillastraight, regular, "unipolar" depressionor is it chocolatedepression with mood swings, manic symptoms, "bipolar" depression? And if bipolar, is it standard bipolar disorderclassic manic-depressive illness with extremes of high and lowor is it a variety of the bipolar "spectrum"recurrent depression with milder highs or other features of bipolar illness?

1. http://www.cnn.com/2003/TECH/science/11/14/coolsc.frogs.fish

2. Holmes OW: Medical essays 18421882. Boston: Houghton Mifflin, 1891

To understand depression, to treat it, and to recover from it, we really need to understand more about the two varieties and especially the bipolar spectrum. This is not a straightforward topic; a great deal of controversy rages in academe, and it has for decades, a sure sign of our ignorance. We have not understood this disease well: depression in all its varieties. We have not studied and examined the bipolar spectrum concept as well as we should. We do not clearly understand, beyond a reasonable doubt, when to use antidepressants and when not to use them. Yet recognizing our lack of knowledge, and increasing our awareness of these problems, is the first step forward.

In the daily work of clinical practice, this awareness of our limitations paradoxically opens new vistas in the diagnosis and treatment of depression. Not all depression is the same, and not all depression responds to antidepressants. In Why Am I Still Depressed? Jim Phelps provides a nuanced and clinically wise rendition of the state of the art. Here he describes the varieties of depression, the concept of the bipolar spectrum, the utility and limitations of antidepressants, the benefits and limits of mood-stabilizing agents, and, perhaps most importantly, how to put it all together. He does all this from the standpoint of a highly informed practicing psychiatrist, someone who observes the academic wars, and then sees what they mean in the daily treatment of patients.