Thursday, July 29, 2010

Mood Disorders -- Tolerable, Bad and Downright Ugly, Part I

A friend recently asked me for a short description of the difference between Major Depressive Disorder and Bipolar II. I didn't keep it short.  This will not surprise my regular readers, and warn my newer ones.

But here is the short answer.  Normal mood cycles within a normal range, sad/okay/glad.  Major depression has bigger distances, between normal and really sad.  Bipolar has the biggest distances.  Bipolar I ranges from really sad to really really up, with more time spend down than up.  Bipolar II moves the base line down from bipolar I.  It goes up, though not so far, and way, way down, lower than the others.

There are other aspects to mood disorders, affecting thought, desire, motivation, energy, sleep, digestion, appetite and even physical pain.  But this astonishingly short answer says way more than your common perception that depression means you are sad; bipolar means you are crazy.

Since I regularly write about these and the other mood disorders in Prozac Monologues, it may be helpful to give the longer answer here.  So today begins another three-part series.  I do seem to like these three-part series.  Things stretch out when I want to make Prozac Monologues both clear and entertaining -- though I suspect that it's mostly people with diagnoses who get the entertaining part.

In the entertaining endeavor, I started playing with squiggly lines, charting the differences among most of the mood disorders, over a longer period of time than you are likely to spend with any one psychiatrist who is interested in the time he/she will spend with you, not the time you will spend with your particular mood disorder, or whatever you get diagnosed with by your next psychiatrist.

These are not the mood charts for managing recurrent depression and bipolar.  Rather, they are much abbreviated and simplified pictures, leaving out lots of details and maybe not following your exact track, you little snowflake you.

This week features the simpler mood tracks, what I call the tolerable.  Let's start with what normal looks like (chart on top), then chronic (in the middle) and single episode unipolar (bottom chart).  All three charts first, then commentary.  It may be easier to follow if you increase your magnification.  My charts were a bit ambitious for the room I have here.


First the legend, meaning, how to read the damn things.  The wavy line is the track of mood over time.  There's your normal mood, the white strip.  Normal mood is not the same every day.  How boring would that be.  But there's normal, and then there's not what you experience every day.  Normal ranges through the white stripe, pink is whey you feel high, blue is low.  Okay, blue would be obvious.  Age is indicated in the white stripe, and the darker vertical lines mark decades.  We start with ten years old and end with sixty, because more wouldn't fit.  Please don't be picky about the lighter lines.  It was way too much bother to change eight to ten, once I noticed it.

Yes, the normal chart is here, too, as a reference point.  Most of you normals know that the rest of us do not occupy a different planet.  Most of you might say to somebody who has a mood disorder, I have been to some dark places, but I realize I haven't been that low.  Some of you say, I know just what you are going through.  I was really depressed when I lost my girlfriendYou just have to...(fill in some platitude.)

If the second is what you say, then I am sorry for your loss and glad that you feel better now, but that is a really stupid thing to say to somebody who has a mood disorder.  I encourage you to stop saying it.  There is a difference between really sad and seriously sick, like the difference between heavy rain and hurricane.  No, you do not know what we are going through.

That said, the difference is not a different planet difference.  We all have moods.  We all occupy a mood continuum.  Actually, nobody is on a different planet.  Even those who are desperately sick with other diagnoses are on the same planet and same continuum of experience.  But that is another post.  And there actually is a limit to the digressions I will travel.

Anyway, normal, chronic depression and unipolar depression share a similar track, as you can see by the relatively similar charts.  That is why I am dealing with these three together, little grasshopper.

The first chart, Normal goes up and down, mostly in the white zone, but occasionally out of it.  Sometimes you feel better, sometimes worse.  These rises and dips usually correspond with life events.  They are situational, to use psych-speak.  So the teen years have a few more extremes.  Duh.  First love strays outside the realm of regular experience -- the old hootie owl hootie-hoos to the dove.  Also outside regular experience is that first breakup -- why do the birds go on singing(**Note to my younger readers -- read these lyrics to your boomer parents and ask them to sing the whole songs.)  Higher for first job, lower for losing it.  Another peak with the birth of the baby.

Then in your mid forties, Nelson Mandela is released from prison, and you are jumping up and down, dancing around the living room.  Or the Cubbies win the World Series, if that's what makes your heart sing.  You call all your friends and talk a mile a minute.  You can't concentrate on work, you read the same news over and over.

If you stayed that way, we would call it manic or hypomanic.  But after a couple days, you normals go back to work.  You hit a lower low when your mother dies.  Maybe you take a sleeping pill for a while.  Eventually you level out.  Later, while you still cry on her birthday and even on yours, you need your friends, not medication.

Your moods are congruent with your life events.  The ups and downs are mostly in the normal range and occasionally extreme.  That's normal.


Chronic depression is not that different.  Your mood line goes up and down for the same events.  It's just that your baseline is set lower, in the blue zone, not the white.  Why?  There doesn't seem to be much research on this question, though there is some debate -- is this personality or disorder?

In the Middle Ages people recognized a variety of temperaments, caused by particular humors.  They didn't mean ha-ha humor; they meant liquids: blood, phlegm, yellow bile, black bile.  Today we would call them personalities.  These humors are what make people sanguine/cheerful, phlegmatic/calm, choleric/angry and melancholic/sad, respectively.  We all have all the humors.  The problem comes when the balance is lost, when one humor begins to dominate, even when not appropriate to the circumstances.

Some people are just melancholic.  It doesn't necessarily mean that they are sick.  People in the Middle Ages even identified occupations that work best for those whose predominant humor is melancholia -- night watchman, gardener, writer.  Is that chronic depression?  Maybe.

I know a couple people who have had chronic depression.  Antidepressants work for them.  There is that problem of Prozac poop-out, a phenomenon that surprised practitioners when their patients started reporting it.  But it makes sense.  Prozac and other serotonin reuptake inhibitors are stimulants.  Like other stimulants, they raise that mood track up a line.  Then after a while (usually years, we hope, if the stimulant is an antidepressant), the body adjusts to the presence of the stimulant.  It returns to its steady state.  With luck, you can find another antidepressant that stimulates in a slightly different way and returns you to that stimulated state.


Okay, now for the bottom chart, major depressive disorder, single episode.  This is the diagnosis you get when you have the symptoms of clinical depression, and you arrive at the doctor's office for the first time.  You have never been diagnosed before.  Notice that its chart tracks with normal, until something knocks you off your pins and throws your brain out of whack, so that it cannot return to its steady state.

The disruption is often a major event.  A baby is born, menopause, somebody dies, you lose your job, you get a divorce.  Something like that.  Normals go into the blue zone, but later return to normal state.  But people with major depressive disorder do not snap out of it.  Whatever coping mechanisms you have are not sufficient to handle this one.  The tipping point of your brain's ability to right itself has tipped too far.

If your mood chart gets stuck in the blue zone and not in the pink, it is called unipolar depression.  For most people with unipolar depression, therapy and exercise are the best treatments, just as effective as antidepressants and without the depressing side effects.  Loss of sexual desire and impotence are pretty depressing, don't you think?  And they don't tell you this when they are writing the prescription, but sometimes sexual side effects don't go away even after you discontinue the antidepressant.  That's really depressing, don't you think?

So therapy may be embarrassing (or so you think), and exercise doesn't fit into your schedule.  But keep the whole picture in mind when you weigh your costs and benefits.  Unless you are seriously and dangerously sick, you may want to try therapy and exercise first.

But if you are seriously suicidal, hit it with all you've got, every tool out there, including antidepressants, hospitalization if necessary to help you survive this disease that kills 15% of those who get it.  Friends, do not believe that your loved one with suicidal depression has too much to live for or is stronger than that or has too much faith to ever do that .  Get him/her help.  Fast.

Pharmaceutical companies do clinical trials before they can market their antidepressants.  They try the medication out on real people to prove that it works better than a placebo.  They want people with single episode unipolar depression in their trials, and screen chronics and recurrents out.  Because people with single episode unipolar get better and stay better anyway.  They don't relapse.

These are the ones for whom the promise is true.  Depression is highly treatable.  If the first antidepressant doesn't work, you have to keep trying.  Another one will.  And that is true.  For about 60% of those who keep trying.  The success rate after two falls off dramatically.

They tell me that about 50% of those who have depression and get treatment will never get it again.  They have true single episode unipolar depression, and that is what they are treated for, with antidepressants if the doctor and/or patient are in a hurry, or with therapy and exercise if the doctor is enlightened and the patient is smart.

If you have to have a mood disorder, single episode unipolar is the one you want.  Meds work.  Therapy improves the quality of your life.  Exercise lengthens your life span, helps you lose weight, gives you more energy and probably improves your sex life, so you want to live longer, assuming you didn't blow your sex life away with those darn antidepressants.  And for that matter, it goes away with or without treatment in 6-18 months anyway.

But get treatment.  Because untreated single episode depression can turn into recurrent depression, at which point the meds won't work so well.  And because medication works, therapy improves the quality of your life, exercise lengthens your life span and all those other good things.

Now, think on this.  Almost everybody who comes into the doctor's office with symptoms of depression is diagnosed with single episode unipolar depression, the first time.  It's when they come in the second time, or when somebody peels them off the wall and drags them in, or the prison calls for an evaluation that the doctor considers another diagnosis, recurrent depression or bipolar I.  And you have to wait a few years, like 7-11 years, before they think about bipolar II.

John McManamy calls unipolar depression bipolar waiting to happen.  Maybe not.  You've got a 50/50 shot that your first episode of unipolar depression will be your last.  Especially if you get treatment for it.  Treatment loads the dice.  Assuming that the diagnosis is correct.

Forget the Diagnostic and Statistical Manual (DSM).  In the real world, a diagnosis of single episode unipolar means first mood disorder.  The significance of that fact will be considered next week, when we move from Tolerable to Bad and Downright Ugly.

photo of lecturer belongs to the Steklov Institute
picture of dice drawn by Steaphan Greene
both are licensed under the 
Creative Commons Attribution-Share Alike 3.0 Unported license.

Charts are my own creation.  You may copy them
if you give my name and the address of the blog.

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