Did you know that more than 43 million adults in our country struggled with Mental Illness in the past year? Half of us will meet the criteria for a diagnosable Mental Health condition at some point in our lives; one quarter by the age of 14 yrs. old.
When it comes to Mental Health conditions, silence is not golden. Silence breeds stigma, and stigma prevents people from seeking help.
Together, we can fight stigma and encourage our family, friends, co-workers, and neighbors to seek help when they need it. Most Mental Illness begins in adolescence, yet it can take years for individuals to seek treatment. Stigma prevents people from seeking life-saving treatment and support. Mental Health Support Community hopes that you will join forces with us to inspire each other and to talk about Mental Illness, so that individuals won’t be afraid to seek the help they need.
“Each person holds so much power within themselves that needs to be let out. Sometimes they just need a little nudge, a little direction, a little support, a little coaching, and the greatest things can happen.” -Pete Carroll-
Psychiatrist:
A Psychiatrist is a doctor who specializes in Emotional, Behavioral, or Mental Disorders..
Therapist/Psychologist:
Therapy helps you learn Self-Awareness and how to process your Emotions. There are many types of Therapy including Talk Therapy or Therapies where you learn specific Coping Skills such as DBT, CBT, and Mindfulness.
See a Mental Health Professional if you experience changes in your behavior, or if your loved ones notice it as well, a diagnosis is the first step to learning more about what you have, and how to treat it. Take notes about what symptoms you experience, and bring them with you to your appointment. Use this Mood Disorder Questionnaire as a starting point: International Bipolar Foundation
All types of Mood Disorders have been associated with Suicide. These include Bipolar Affective Disorder, Depressive Episode, Recurrent Depressive Didorder, and persistent Mood Disorders, (e.g. Cyclothymia, and Dysthymia), which form categories F31-F34 in ICD-10 (1). Suicide is therefore a significant risk in unrecognized Depression. Depression has a high prevalence in the general population and is not recognized by many as a Disease. It is estimated that 30% of patients seen by a Physician are suffering from Depresson. Roughly 60% of those who do seek treatment initially contact a General Practitioner. It is a special challenge for the Physician to work with both Physical Disease, and Psychological Disorders simultaneously. In many instances, Depression is masked and patients present only with the somatic complaints.
These include the following:
“7 Emotional Well-Being :
Such as perceived life satisfaction, happiness, cheerfulness, peacefulness.
“8 Psychological Well-Being :
Such as self-acceptance, personal growth including openness to new experiences, optimism, hopefulness, purpose in life, control of one’s environment, spirituality, self-direction, and positive relationships.
“9 Social Well-Being :
Social acceptance, beliefs in the potential of people and society as a whole, personal self-worth and usefulness to society, sense of community.
The former Surgeon General notes that there are social determinants of Mental Health as there are social determinants of General Health that need to be in place to support Mental Health. These include adequate housing, safe neighborhoods, equitable jobs and wages, quality education, and equity in access to quality Health Care.
Depression is a real and debilitating condition that is often misunderstood by family and friends. Its meaning can range from a prolonged period of sadness to an actual mental illness with specific symptoms. Find and share experiences with others who are going through the same struggles.
Bipolar disorder is not just a single disorder, but a category of mood disorders marked by periods of abnormally high energy and euphoria, often accompanied by bouts of clinical depression. This is the place to talk about your experience with bipolar disorder, learn from others’ experiences, and find support.What is Bipolar Disorder? Bipolar disorder, formerly known as manic-depressive illness, is a brain and behavior disorder characterized by severe shifts in a person’s mood and energy, making it difficult for the person to function. More than 5.7 million American adults or 2.6 percent of the population age 18 or older in any given year have bipolar disorder. The condition typically starts in late adolescence or early adulthood, although it can show up in children and in older adults. People often live with the disorder without having it properly diagnosed and treated.
Anxiety is a physical condition marked by intense and persistent feelings of distress, fear, angst or dread. General Anxiety caused by routine day-to-day stresses usually passes quickly and is experienced by almost everyone at one time or another. However, such feelings that linger over time and are very difficult to cope with, and which lack a clear cause, may indicate an Anxiety Disorder.
Borderline Personality Disorder BPD is an extremely difficult mental illness to deal with and I am hoping to be able to share experiences, advice and support to help people living with it.
Obsessive-compulsive disorder (OCD) is a psychiatric disorder, more specifically, an anxiety disorder. OCD is manifested in a variety of forms, but is most commonly characterized by a subject’s obsessive (repetitive, distressing, intrusive) thoughts and related compulsions (tasks or rituals) which attempt to neutralize the obsessions.
A panic attack is a period of intense fear or discomfort, typically with an abrupt onset and usually lasting no more than thirty minutes. Symptoms include trembling, shortness of breath, heart palpitations, sweating, nausea, dizziness, hyperventilation, and sensations of choking or smothering. Panic attacks can be very sudden, appear to be unprovoked, and are often disabling.
Agoraphobia is an anxiety disorder, often precipitated by the fear of having a panic attack in a setting from which there is no easy means of escape. As a result, sufferers of agoraphobia may avoid public and/or unfamiliar places. In severe cases, the sufferer may become confined to their home, experiencing difficulty traveling from this “safe place.”
A phobia (from the Greek “fear”), is a strong, persistent fear of situations, objects, activities, or persons. The main symptom of this disorder is the excessive, unreasonable desire to avoid the feared subject. When the fear is beyond one’s control, or if the fear is interfering with daily life, then a diagnosis under one of the anxiety disorders can be made.
Eating disorders are marked by an obsessive need to control the intake and/or purging of food. This community is dedicated to those struggling on the road to recovery. Join to discuss your experience with others and find support. Get advice, ask questions, and meet others who are going through similar struggles.
Dissociative identity disorder is a diagnosis described as the existence in an individual of two or more distinct identities or personalities, each with its own pattern of perceiving and interacting with the environment. At least two of these personalities are considered to routinely take control of the individual’s behavior, and there is also some associated memory loss, which is beyond normal forgetfulness. This memory loss is often referred to as “losing time”. These symptoms must occur independently of substance abuse or a general medical condition. Dissociative identity disorder was initially named multiple personality disorder, and, as referenced above, that name remains in the International Statistical Classification of Diseases.
Abuse is a general term for the treatment of someone that causes some kind of harm (to the abused person, to the abusers themselves, or to someone else) that is unlawful or wrongful. No one deserves abuse, period. Abuse can be emotional, physical, or sexual.
PTSD / Find support with others who have gone through a traumatic experience. Whether you have chronic or acute PTSD, we are here for you.
Attention deficit/hyperactivity disorder (ADHD) and attention deficit disorder (ADD) are more common than you might think. It is a syndrome that exhibits symptoms such as hyperactivity, forgetfulness, mood shifts, poor impulse control, and distractibility. Join others who suffer from these conditions and share your experiences.
Loneliness is an emotional state in which a person experiences a powerful feeling of emptiness and isolation. Loneliness is more than the feeling of wanting company or wanting to do something with another person. Loneliness is a feeling of being cut off, disconnected and alienated from other people. he lonely person may find it difficult or even impossible to have any form of meaningful human contact. Lonely people often experience a subjective sense of inner emptiness or hollowness, with feelings of separation or isolation from the world… Why Do People Get Lonely? People can experience loneliness for many reasons, and many life events are associated with it. The lack of friendship relations during childhood, adolescence, and etc….
Schizophrenia is a psychiatric diagnosis that describes a mental disorder characterized by impairments in the perception of reality and by significant social dysfunction. Untreated schizophrenia is typically characterized by demonstrating disorganized thinking and experiencing delusions or auditory hallucinations.
-Seasonal affective disorder, also known as S.A.D., winter depression or the winter blues is an affective, or mood, disorder. Most SAD sufferers experience normal mental health throughout most of the year, but experience depressive symptoms in the winter or summer. The condition in the summer is often referred to as Reverse Seasonal Affective Disorder. Seasonal mood variations are believed to be related to light. An argument for this view is the effectiveness of bright light therapy. SAD is measurably present at latitudes in the Arctic region, such as Finland where the rate of SAD is 9.5% Cloud cover may contribute to the negative effects of SAD. SAD can be a serious disorder and may require hospitalization.
Bipolar or Manic Depressive Disorder is a Mood Disorder that causes radical emotional changes and mood swings, from Manic highs to Depressive lows. The majority of Bipolar individuals experience alternating episodes of Mania and Depression from a minor state of life, to lifelong disability. The information here should not be used as a substitute for seeking Medical care for Diagnose or Treatment. We are strictly Volunteered based. The Group is being created for all to come via “Multiple” Mental Disorders they may be going through with Bipolar Disorder. Bipolar Disorder and other serious Brain Diseases are an extreme challenge for the individual and the entire family.
Mental Health and Wellness disorders are illnesses that involve the body, mood, spirit, and thoughts! It affects how one eats, and sleeps, the way one feels about oneself, and the way one thinks about things! Sometimes referred to as Psychiatric or Psychologic Disorders, Mental Health Disorders are caused by complex interactions between Physical, Psychologic, Social, Cultural, and Hereditary influences. They involve disturbances in thinking, emotion, and/or behavior. Small disturbances in these aspects of life are common, but when such disturbances distress the person greatly, interfere with daily life, or both, they are considered Mental Illness or a Mental Health Disorder. The effects of Mental Illness may be long-lasting or temporary.
We believe that people become empowered to help themselves and others when they feel a part of something. Sharing in your journey with others will help take the focus off of yourself and in return I feel, and have heard others as well state that they felt much gratification that their story, and or struggles just may be for a reason, to help those struggling, and in reaching out to those whom don’t have a voice yet! We offer to help those individuals diagnosed by sharing coping mechanisms, in hopes to learn from each other’s struggles, and possibly be able to lend a helping hand in helping someone else…. Communicating, sharing, and connecting with others in a Community will have a positive effect on healing in your life….
There’s a strong link between good mental health and good physical health, and vice versa. In the other direction, depression and other mental health issues can contribute to digestive disorders, trouble sleeping, lack of energy, heart disease, and other health issues. There are many ways to keep your mind and mood in optimal shape. Exercise, healthy eating, and stress reduction techniques like meditation or mindfulness can keep your brain — and your body — in tip-top shape. When mood and mental health slip, doing something about it as early as possible can keep the change from getting worse or becoming permanent. Treating conditions like depression and anxiety improve quality of life. Learning to manage stress makes for more satisfying and productive days.
If you have been diagnosed with any Mental Health Disorder we ‘welcome’ you to this Peer Support Community. We offer you to give and gain Peer Support through your journey of Symptoms, Triggers, Treatment, and Recovery.
We do “NOT” participate in our Support Group Community as Professionals!
We are Advocates on The Road to Recovery!
We believe that traditionally in Society, Mental Health concerns have been stigmatized with people often expressing both prejudice and discrimination toward those with a Mental Disorder Diagnosis. Furthermore, people with Mental Health concerns often have nowhere to turn for Support. We offer a caring and Safe Environment.
YOU MUST BE 18 YEARS OR OLDER TO JOIN IN OUR SUPPORT GROUP COMMUNITY…
If you or someone you know needs immediate help in the U.S., call the line for hope to talk to someone live in your local area. They can listen to you and direct you to local resources if further assistance is needed. If someone has talked to you about suicide, and you believe they are currently a threat to themselves or someone else but won’t take your help, call 911!
1- (800)273-8255 …..1-800-273-TALK National Suicide Prevention Lifeline
1-(877)838-2838 …..1-877-Vet2Vet Veterans Peer Support Line
Death or terminal illness of relative or friend. Divorce, separation, broken relationship, stress on family. Loss of health (real or imaginary). Loss of job, home, money, status, self-esteem, personal security. Alcohol or drug abuse. Depression. In the young depression may be masked by hyperactivity or acting out behavior. In the elderly it may be incorrectly attributed to the natural effects of aging. Depression that seems to quickly disappear for no apparent reason is cause for concern. The early stages of recovery from depression can be a high risk period. Recent studies have associated anxiety disorders with increased risk for attempted suicide.
Emotional and behavioral changes associated with Suicide:
Overwhelming Pain: pain that threatens to exceed the person’s pain coping capacities. Suicidal feelings are often the result of longstanding problems that have been exacerbated by recent precipitating events. The precipitating factors may be new pain or the loss of pain coping resources. Hopelessness: the feeling that the pain will continue or get worse; things will never get better. Powerlessness: the feeling that one’s resources for reducing pain are exhausted. Feelings of worthlessness, shame, guilt, self-hatred, no one cares. Fears of losing control, harming self or others. Personality becomes sad, withdrawn, tired, apathetic, anxious, irritable, or prone to angry outbursts. Declining performance in school, work, or other activities. (Occasionally the reverse: someone who volunteers for extra duties because they need to fill up their time.) Social isolation; or association with a group that has different moral standards than those of the family. Declining interest in sex, friends, or activities previously enjoyed. Neglect of personal welfare, deteriorating physical appearance. Alterations in either direction in sleeping or eating habits. (Particularly in the elderly) Self-starvation, dietary mismanagement, disobeying medical instructions. Difficult times: holidays, anniversaries, and the first week after discharge from a hospital; just before and after diagnosis of a major illness; just before and during disciplinary proceedings. Undocumented status adds to the stress of a crisis.
Suicidal Behavior:
Previous Suicide attempts, mini-attempts. Explicit statements of suicidal ideation or feelings. Development of suicidal plan, acquiring the means, rehearsal behavior, setting a time for the attempt. Self-inflicted injuries, such as cuts, burns, or head banging. Reckless behavior. (Besides suicide, other leading causes of death among young people in New York City are homicide, accidents, drug overdose, and AIDS.) Unexplained accidents among children and the elderly. Making out a will or giving away favorite possessions. Inappropriately saying goodbye. Verbal behavior that is ambiguous or indirect: I’m going away on a real long trip., You won’t have to worry about me anymore., I want to go to sleep and never wake up., I’m so depressed, I just can’t go on., Does God punish suicides?, Voices are telling me to do bad things., requests for euthanasia information, inappropriate joking, stories or essays on morbid themes.
The majority of the population at any one time does not have many of the warning signs and has a lower suicide risk rate. But a lower rate in a larger population is still a lot of people – and many completed suicides had only a few of the conditions listed above. In a one person to another person situation, all indications of suicidality need to be taken seriously.
The Samaritans
Call If you are having thoughts of harming yourself or you are being abused, please call us. These are serious issues that are best handled in one-on-one conversations with counselors. Always Open! Counselors are ready for your call 24/7. 1-800-448-3000
Text with a counselor for free with the following carriers: AT&T, Verizon, T-Mobile, Sprint, Virgin, Cricket, Nextel, Boost, MetroPCS. (standard message & data rates may apply for other carriers)
Every day, 4PM to 1AM CST.
Text VOICE to 20121 to start.
Text STOP to opt out.
For more information about the service, text HELP to 20121.
For end user privacy and terms & conditions Visit Link Below :
Prevention Pays Text Enterprising Text Platform
uicide Prevention / Immediate Online Phone # Support Listing by States and Countries Visit Link Below :
“USA” Listing by “State” Hot Line / and “Out of the Country International” Hot Line
The first candle represents our grief. The pain of losing you is intense. It reminds us of the depth of our love for you. This second candle represents our courage. To confront our sorrow, To comfort each other, To change our lives. This third candle we light in your memory. For the times we laughed, The times we cried, The times we were angry with each other, The silly things you did, The caring and joy you gave us. This fourth candle we light for our love. We light this candle that your light will always shine. As we enter this holiday season and share this night of remembrance with our family and friends. We cherish the special place in our hearts that will always be reserved for you. We thank you for the gift your living brought to each of us.
Let these positive affirmations from Louise Hayheal your life and bring you success. Repeat these to yourself daily and you will see a positive change in your mindset, your actions, and your life.
1. “Life supports me in every possible way.”
2. “I am in the process of making positive changesin all areas of my life.”null
3. “It does not matter what other people say or do. What matters is how I choose to react and what I choose to believe about myself.”
4. “I am good enough.”
5. “I forgive everyone in my past for all the perceived wrongs. I release them with love.”
6. “I let go of all fear and doubt, and life becomes simple and easy for me.”null
7. “Everything I need comes to me at the perfect time.”
8. “I feel glorious, dynamic energy. I am active and alive.”
9. “Today is going to be a really, really good day.”
10. “I am beautiful and everybody loves me.”
11. “I deserve only good in my life.”
12. “My good is constantly coming to me, so I relax and enjoy my life.”
27. “I am grateful for every experience I have ever had as it has shaped me into the person I am today, and that is exactly who I am supposed to be right this very moment.”
28. “I enjoy today and cheerfully look forward to tomorrow.”null
29. “Life always reveals to me what I need to know at just the right moment.”
30. “I choose to make the rest of my life the best of my life.”
31. “I give my body what it needs.”
32. “I trust the process of life to always be here for me.”
33. “Today I mentally wrap each person I meet in a circle of love.”
36. “Life brings me only good experiences. I am open to new and wonderful changes.”https://3b3b8af48fb8266b78a9d04d27ea1d2d.safeframe.googlesyndication.com/safeframe/1-0-38/html/container.html
39. “Today I listen to my feelings, and I am gentle with myself. I know that all of my feelings are my friends.”
40. “I am a magnet for money. Prosperity of every kind is drawn to me.”
41. “Every moment presents a wonderful new opportunity to become more of who I am.”
42. “I lovingly do everything I can to assist my body in maintaining perfect health.”
43. “I am deeply fulfilled by all that I do.”
44. “I have plenty of time to do what I need to do. Time expands for me.”https://3b3b8af48fb8266b78a9d04d27ea1d2d.safeframe.googlesyndication.com/safeframe/1-0-38/html/container.html
45. “I am an open channel for creative ideas.”
46. “I give myself permission to be prosperous.”
47. “I now see opportunities for abundance everywhere. I am blessed.”
48. “My day begins and ends with gratitude and joy.”
49. “I affirm that I have the power to heal myself.”
50. “Today I look at all the positive things in my life, and I am grateful for them.”
Share this with others, so that they too may be healed from within.
Multiple psychiatric comorbidities, including ADHD, anxiety, personality disorders, eating disorder and substance use disorders interfere with the diagnosis and treatment of bipolar depression, and likely contribute to increased disease morbidity and mortality, including increased suicide risk64,65. Psychiatric comorbidity is reported in 90% of patients with bipolar I or II disorder9, with anxiety, impulse control and substance use disorders found to be two to three times more prevalent than in the general population9,66. Comorbid anxiety and bipolar disorder is specifically associated with earlier age of the first depressive episode, greater number of depressive episodes, fewer days well, longer time to recovery from a depressive episode, shorter time to relapse, poor role functioning and reduced quality of life67,68.
At least 50% of adults with bipolar disorder experience substance use disorders at some point in their lives69, making this both an important comorbidity and a potential differential diagnosis criterion. Similar to comorbid obesity, substance use disorder is thought to be associated with an aberrant reward–motivation neural network55. The prognosis for substance use disorder is mainly predicted by the number and severity of comorbid episodes of bipolar depression. People with alcohol use disorder are at four times greater risk of having bipolar disorder than are people without alcohol use disorder; illicit drug users have a five times greater risk of having bipolar disorder than nonusers70. Patients with these comorbid disorders have a much greater burden of illness than other patients, with sequelae including delayed recovery from mood episodes, increased suicidality, functional impairment, decreased medication adherence and decreased quality of life70.
It is of additional concern that a comorbid syndrome of bipolar disorder and ADHD appears to be common, although more studies are needed to clarify its diagnostic validity and treatment approach. Comorbid ADHD and bipolar disorder, which is present in up to 47% of adult ADHD populations and 21% of bipolar disorder populations, has a more severe course of illness compared with that of bipolar disorder alone, and high rates of comorbidity with other psychiatric disorders71.
Comorbid eating disorders, which are particularly associated with the depressive phases of bipolar disorder72, have a much higher prevalence for patients with bipolar disorder (range, 6–27%) than for individuals in the general population (4–10%)73,74. Binge eating behavior is an important consideration for clinicians since it may serve as an early predictor of eating disorders in patients with bipolar spectrum disorder75.
Diagnosis
Given the high number of comorbid conditions and differential diagnoses associated with bipolar disorder, correct diagnosis is a challenge for healthcare professionals. In a survey of bipolar patients involved with National Depressive and Manic–Depressive Association support groups, 69% reported that they were initially misdiagnosed by psychiatrists, with a mean of 3.5 other diagnoses received and 4 psychiatrists consulted before an accurate diagnosis was received76. For 60% of patients, the misdiagnosis was MDD, with women more likely than men to receive an MDD diagnosis (68% vs. 43%). Only 20% of patients with bipolar disorder and a depressive episode are diagnosed with bipolar disorder within the first year of seeking treatment77; the mean delay between the onset of illness and diagnosis is 5 to 10 years78. Primary care physicians treat approximately half of all patients with mental illness79, and among patients who screened positive for bipolar disorder, the diagnosis was missed by primary care physicians 78% of the time80. Given the progressive nature of bipolar disorder, timely and accurate diagnosis is extremely important and clinicians should be especially attentive to symptoms that are suggestive of the disorder.
Diagnostic criteria require that patients with bipolar depression have a history of at least one manic episode and present with either a depressed mood most of the day, nearly every day, or loss of interest and pleasure in all activities (anhedonia); additional symptoms may include weight loss, insomnia, psychomotor agitation or retardation, feelings of worthlessness or guilt, decreased ability to concentrate, and recurrent thoughts of death or suicidal ideation4. Depressive symptoms must be severe enough to cause clinically significant distress and impairment in social or occupational functioning. Diagnosis can be complicated because the criteria for a bipolar depressive episode are the same as those for a unipolar depressive episode, making an accurate history of mania or hypomania the crucial differentiating factor. In addition, while patients are typically troubled by depressive symptoms, they may not recognize that manic or hypomanic symptoms are also part of the illness so an incomplete symptomatic profile may be reported to the clinician, further clouding the diagnostic picture.
The DSM-5 also provides a mixed features specifier that can be applied to manic or hypomanic episodes that have depressive features and, conversely, to depressive episodes that have manic features. Patients must meet the full criteria for a manic/hypomanic episode or depressive episode and concurrently have at least three symptoms emanating from the opposite pole. Approximately 25–35% of patients have been identified as having mixed features as part of a depressive mood episode in either bipolar disorder or unipolar depression81. Accurate diagnosis is important since mixed features in either illness are associated with greater illness complexity, reduced treatment response, lack of response to antidepressants, worse outcomes and increased risk of suicide82. In bipolar disorder, even mood episodes that appear to be purely depressive have at least subtle manic-like symptoms, such as distractibility, racing thoughts, irritation and agitation, that are present in up to two thirds of patients83. Specific recommendations for managing mixed features are limited and there are currently no approved treatments82.
Differential diagnosis
The diagnosis of bipolar disorder can be challenging because the first episode of mood disturbance in bipolar disorder is usually depression, not mania, and most patients seek treatment for depressive symptoms84–86. Initial misdiagnosis of patients with bipolar disorder results in delay of appropriate treatment and the potential for mistreatment with antidepressant monotherapy, which may subsequently increase the risk of recurrence and chronicity in this progressive disorder27,84. The primary differential diagnoses are major depression, anxiety disorders, ADHD, personality disorder, drug and alcohol misuse, schizophrenia, in addition to consequences of trauma/brain injury.
Although nothing can replace careful clinical assessment, screening tools may help to identify bipolar disorder or rule out an incorrect diagnosis in primary care and clinical practice. For example, the MDQ is an easy-to-use self-report instrument consisting of 13 questions that assess clustering of symptoms and functional impairment in bipolar disorder12,16,87. When used with follow-up questioning and evaluation, the MDQ has been shown to have good sensitivity (∼70%) and specificity (∼90%) for diagnosing bipolar disorder12,87. Advanced practice registered nurses reported that screening depressed patients with validated screening tools could reduce the time to correct diagnosis and treatment of bipolar depression88, suggesting that screening tools may improve diagnostic accuracy in primary care.
Unipolar depression
Misdiagnosis of unipolar depression in patients with bipolar depression is a common and challenging problem. Of patients with bipolar disorder, a majority are initially misdiagnosed with MDD, leading to the possibility of incorrect treatment and poor outcomes (Figure 2)76.
Since the diagnostic criteria for a major depressive episode are the same in bipolar depression and MDD, with no single constellation of symptoms diagnostic for either disorder, clinicians should be aware that specific symptoms have a higher probability of being associated with each diagnosis (Figure 3)7.
Figure 3. Symptoms with potential diagnostic utility in bipolar and unipolar depression1,7.Display full size
In patients from academic centers followed up for at least 1 year in the National Institute of Mental Health Collaborative Depression Study, approximately 25% of patients initially diagnosed with MDD subsequently experienced a manic or hypomanic episode, resulting in a revised diagnosis of bipolar I or II disorder89. The presence of subthreshold hypomania predicted progression from unipolar depression to bipolar depression. Misdiagnosis as unipolar depression is more likely when patients present to clinicians during a depressive episode since unipolar depression is more common and it is difficult to retrospectively establish a manic/hypomanic history90. Misdiagnosis as unipolar depression is also more likely if the patient is evaluated early in the course of illness, since the first bipolar mood episodes are likely to be depressive, or if there is no validating information from family/caregivers or friends91,92. Patients with greater number of failed antidepressant trials are more likely to have bipolar disorder7, which is a clinical concern since the use of monotherapy antidepressants in bipolar depression is not backed by a strong evidence base, although it is an exceedingly common practice. Concerns pertaining to the use of antidepressant treatment without mood stabilizing treatment include the possibility of increased acute risk of switch from depression to mania/hypomania7,93, as well as a delay in receiving approved bipolar depression treatment.
Attention deficit hyperactivity disorder
Differentiating ADHD and bipolar disorder is complicated by similarities between the disorders including early age of onset, reciprocal comorbidity, similar psychiatric comorbidities, chronic course and persistence into adulthood; both disorders are also associated with impaired educational, occupational and interpersonal functioning, and increased morbidity and mortality in adulthood94. Clinical differentiation is most challenging when ADHD is comorbid with conduct disorder and/or oppositional defiant disorder, since the presenting symptoms (e.g. temper tantrum, aggressive behavior) can overlap with symptoms of a manic or mixed state. In uncomplicated cases, the appearance of prominent mood dysregulation, sleep irregularities and aggressive behaviors are more likely to predict a diagnosis of bipolar disorder than ADHD, especially if there is impulsive behavior associated with spending money, sex, or tobacco, alcohol or drug use94. Conversely, fidgeting, restlessness, and inefficient and disorganized behaviors arising from inattentiveness, distractibility and forgetfulness, often suggest ADHD.
Substance abuse
Clinicians treating patients for substance abuse should be aware that approximately 60% of patients with bipolar I disorder have a lifetime diagnosis of substance use disorder95. Comparatively, just one third of patients with MDD have a comorbid substance use disorder, making this a diagnostically important symptom96. Substance abuse and bipolar disorder are both associated with mood symptoms, anxiety symptoms, family history of mood/anxiety problems, disruptive behaviors and relationship problems97. Patients with bipolar disorder and comorbid substance abuse are likely to have developed substance abuse disorder before age 13; comorbid occurrence is also associated with cocaine and amphetamine use, episodic substance use, mood problems that persist without substance use, manic symptoms and a family history of bipolar disorder97. Differentially, substance abuse that occurs independently of bipolar disorder is more likely to have onset after age 13, and to be associated with multiple substances, continuous substance use, no manic/hypomanic symptoms and family history of anxiety disorders97.
Borderline personality disorder
Since emotional dysregulation and depression accompanied by negative cognitions are ubiquitous features of both borderline personality disorder and bipolar disorder98, mistaken diagnosis of these two conditions is predictable. The lifetime co-occurrence of borderline personality disorder and bipolar disorder is 27.6%99, with evidence that 15% of patients with bipolar disorder have comorbid borderline personality disorder. Having either disorder may increase the risk that the other disorder will be misdiagnosed100. To differentiate the disorders, clinicians should look for emotional shifts between depression and rage for borderline personality disorder and between depression and mania for bipolar disorder; depression and rage in borderline personality disorder can mimic a mixed bipolar episode98. In borderline personality disorder, mood shifts tend to be rapid, with changes lasting hours to days and closely linked to interpersonal events, whereas bipolar mood shifts tend to be more enduring (except in cases of rapid cycling or mixed features). Additionally, patients with borderline personality disorder tend to have more intense and severe disruptions in interpersonal relationships than do patients with bipolar disorder. A longitudinal approach to diagnosis may be best practice for a clinician since typically the onset of borderline personality is around puberty, while bipolar disorder usually appears in late adolescence or early adulthood98. Borderline personality symptoms are also likely to become less striking as the patient ages, while bipolar disorder persists and depressive symptoms may possibly become more severe and disabling with aging. To date, borderline personality disorder has not demonstrated response to pharmacological therapy, with psychological and psychosocial therapies the current mainstays of management.
Treatment
The first step in treatment for bipolar disorder is confirming the diagnosis, including a history of a manic or hypomanic episode, and determining the nature of the presenting episode. Timely diagnosis is extremely important since bipolar disorder is a highly progressive illness1. In acute management, the primary goal of treatment is to stabilize presenting symptoms with minimal adverse events and ensure the patient’s safety. Although there are many first-line acute treatment options for a manic episode, including most antipsychotic agents that are approved for bipolar I disorder and mood stabilizing drugs (e.g. lithium, lamotrigine)93,101, only a few treatment options are available to treat bipolar depression. Immediate- and extended-release quetiapine, fluoxetine/olanzapine combination, cariprazine and lurasidone are the only medications currently approved by the FDA to treat bipolar depression; cariprazine and quetiapine are the only agents that are approved to treat symptoms of both mania and depression associated with bipolar I disorder. According to current treatment guidelines, antidepressants should not be used as monotherapy in patients with bipolar depression since available evidence does not support their efficacy and there are concerns about safety related to mood switching93,102,103. The limited number of approved treatments for bipolar depression is a clinical concern since not all patients respond to available treatment options and response may decrease over time. A comprehensive literature review found consistent evidence suggesting that pharmacological and psychosocial treatment in the earlier stage of illness resulted in better outcomes for response, relapse rate, time to recurrence, symptomatic recovery, remission, psychosocial functioning and employment104.
Possibly due to the long-standing, but discredited, view that bipolar II is a less severe form of bipolar disorder, its treatment has been understudied relative to bipolar.
and the evidence base for treatment is not well established93. Additionally, there are currently no approved treatments for mixed bipolar states and treatment guidelines for this symptom profile are limited82; antidepressants have been shown to be an ineffective treatment for mixed bipolar depression105.
Although antipsychotics and mood stabilizers are the foundation of treatment in bipolar disorder, it is estimated that between 40% and 50% of patients are nonadherent or only partially adherent to their treatment106. Several studies have reported that specific demographic and illness characteristics, including younger age, male sex, being unmarried, minority ethnicity, comorbid substance abuse, illness severity, inadequate social support and poor insight, may be associated with nonadherence106. Negative patient attitudes are of further importance since fear of adverse events, denial of illness severity and the need for treatment, perceived medication ineffectiveness, fears of medication dependence, and the stigma of being on medication are cited as additional contributing factors. The consequences of nonadherence can be serious and patients may experience poor outcomes, worse quality of life, functional impairment, and increased risks of relapse, rehospitalization and suicidality106. Although manic symptoms have been particularly noted in association with treatment nonadherence in bipolar disorder, bipolar depression may contribute to social isolation or a lack of engagement in self-care that may precipitate or worsen nonadherence107.
All effective treatments for bipolar disorder have potential side effects that need to be acceptable to patients to maximize treatment adherence and favorable outcomes; monitoring for common adverse effects should be common practice for clinicians. Although individual antipsychotic agents are associated with different propensities for causing specific adverse events, common effects associated with atypical antipsychotics include weight gain, extrapyramidal symptoms, sedation and metabolic dysfunction93. Similarly, mood stabilizers used to treat bipolar disorder, including lithium, divalproex, carbamazepine and lamotrigine, have a variety of adverse effects including weight gain, gastrointestinal symptoms, renal toxicity, cardiovascular effects, tremor, sedation and hypothyroidism93. Patients on lithium, divalproex or carbamazepine need to have their serum medication levels monitored regularly to ensure that that they are in a therapeutic range to avoid toxicity.
The potential for drug–drug interactions is a particular concern for patients with bipolar disorder, who tend to have complex and varied treatment regimens108. Given the long-term, chronic, progressive nature of bipolar disorder and the level of associated impairment, a strategy that combines pharmacological treatment, psychosocial intervention and lifestyle approaches is recommended beginning at the first episode. Psychosocial interventions that have shown efficacy include cognitive behavioral therapy, psychoeducation, interpersonal and family psychotherapy, and functional remediation1. Awareness of the increased risk of cardiovascular disease and metabolic abnormalities in patients with bipolar depression should also prompt clinicians to perform physical examinations to assess risk factors. Additionally, healthy behaviors, such as smoking cessation, exercise and weight control, should be encouraged and patients should be monitored for treatment-related issues and suicidality.
Unmet needs
Given the large amount of time spent unwell as a result of mood episodes and subsyndromal symptoms, as well as considerable levels of associated impairment and disability, it is not surprising that there are significant unmet needs in bipolar disorder and bipolar depression. Studies of treated patients with bipolar I disorder have found residual morbidity in 40% of patients during the follow-up period, with approximately three quarters of it related to depressive or dysthymic symptoms30,109,110. Unresolved depressive morbidity is likely an important contributor to substance abuse, functional disability and excess mortality in bipolar disorder111.
Unmet needs in bipolar disorder may differ considerably when comparing the viewpoints of the patient, provider and caregivers; current research suggests that patient-centric outcomes should be recognized as important factors in the assessment and treatment of bipolar depression112. From the patient perspective, unmet needs are generally associated with treatment satisfaction, quality of life, level of functioning and general health (Figure 4)102,113.
Medication side effects and concerns about the return of symptoms were reported by patients with bipolar depression to be the leading factors related to decisions about changing a treatment or trying a new one114. Intolerable adverse events are a frequent cause of treatment nonadherence, although events that are often thought of as mild and/or transient by clinicians (e.g. gastrointestinal issues, dry mouth) were reported as the reason for treatment discontinuation for 20–30% of patients who were surveyed by the Depression and Bipolar Support Alliance115. Weight gain was reported as the treatment-emergent event most commonly related to medication discontinuation in real-world treatment; lethargy, anxiety, shaking/trembling and suicidal thoughts were also highly associated with treatment discontinuation. Circadian rhythm disturbance, as shown by sleep alterations during and between episodes of bipolar depression, is another unmet patient need that may represent a risk factor for relapse/recurrence and comorbidity, making it a frequent target of treatment116.
From a clinician’s perspective, better patient education and support, referral to specialist care as necessary, improved treatment effectiveness, and better medication adherence have been identified as pressing clinical needs102. Since bipolar illness is increasingly recognized as an illness that is treated in primary care, complex factors such as diagnosis, psychiatric comorbidities, greater suicide risk and confusion about appropriate treatment may become impediments to treatment success117. Knowing the specific symptoms that differentiate bipolar and unipolar depression, using screening tools to aid diagnosis and using evidence-based treatment guidelines, which recommend ongoing symptom/side-effect monitoring, psychosocial interventions, medication monitoring, and dose adjustment or switching to a different oral antipsychotic, may help improve treatment adherence for patients in clinical practice and ease some burdens for primary care providers117,118.
Caregivers also experience considerable burdens (e.g. depression, work disruption) that adversely affect patient recovery and the home environment102, highlighting the need for a strong alliance among the patient, the family and the mental health provider113. To meet patient and caregiver needs, clinicians should rely on evidence-based practices in the clinic and seek out education pertaining to accurate diagnosis and appropriate treatment102.
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