Did you know that about half the people
with bipolar disorder spend more time
in one phase over the other,
and which phase that is can make a difference
in how well you do?
I'll explain.
I'm Dr. Tracey Marks, a psychiatrist,
and I make mental health education videos.
Bipolar disorder is a mood disorder, where you have episodes
of depression and separate episodes of mania or hypomania.
You can watch other videos that I'll link to this one
that give details of the symptoms
of mania, hypomania, and depression.
The disorder is called bipolar,
because you experience symptoms
at opposite end of a mood spectrum,
like North and South poles.
The two types of bipolar disorder
are type one where you have episodes of depression and mania
and type two where you have episodes
of depression and hypomania.
Within both of these forms of the disorder,
you can also have a mixed type, where you have a combination
of depression and mania happening at the same time,
or a rapid cycling type,
where you have four or more separate episodes in a year.
That's a general overview.
Now here's the newer information.
Not everyone experiences bipolar disorder
in the same way of switching back and forth
between mania and depression.
About half of the people with bipolar one or two,
spend a predominant amount of time
at one pole over the other.
This is called predominant polarity
and it's defined as having at least twice as many episodes
of one pole over the other.
Here's what it can look like.
If you are Depression Polarity Predominant or DPP,
chances are your first ever episode was major depression,
and you probably had a few depressive episodes
before you had a manic or hypomanic episode.
Because you started with depression,
it would not have been obvious at the beginning
that your depression was part of bipolar disorder,
so you may have gone years being treated
as unipolar depression with antidepressants only,
but the standard treatment for bipolar disorder
is a mood stabilizer first.
So many times, the person who shows up
with unrecognized bipolar depression
and gets put on an antidepressant
may not do well on the medication.
Antidepressants tend to make bipolar disorder worse
by triggering rapid cycling or creating mixed episodes,
where you have this awful agitated depression.
I say antidepressants tend to do this,
because it's the trend, but it's not an absolute.
Some people with bipolar disorder can tolerate
small doses of antidepressants as long as they are also
on a mood stabilizer.
For a minority of people, the antidepressant
is the only thing that elevates their mood.
Nevertheless, the recommendations are to still use
mood stabilizers to treat the depression episodes.
But admittedly, our antidepressant treatment options
are not as good as the antimanic options,
and this is why people with the depression predominance
tend to spend more time not feeling well.
Some people with the depression predominance can have cycles
of depression followed by mania,
and then an interval with nothing going on,
but at some point, they will have back-to-back
depressive episodes such that they may forget
that there ever was a manic episode in the past.
In fact, forgetting about the mania can be another reason
for a worse treatment outcome.
Let's say you have a hypomanic episode
and your doctor adds a mood stabilizer
to your antidepressant.
You do well for years on this regimen
except for a few periods where your mood dips,
and then it recovers.
You switch insurance and get a new doctor.
Your new doctor gets your history
and you tell them about your depressions
and forget the time when you were hypomanic,
because it was years ago.
You've gained a lot of weight from the Abilify
that your doctor added back then, and together,
you and your new doctor decide to get rid of it.
Your new doctor doubts that you have bipolar disorder,
because they didn't hear much about the mania
when you were talking to them.
And so now they start treating you for unipolar depression.
Months after stopping the Abilify, you get more depressed.
Your doctor adds a new antidepressant,
which triggers a mixed manic state.
Now things are a mess and your doctor has to scramble
to get you out of that state.
Unfortunately, this situation is all too common,
but let's look at the other pole.
People who have the Mania Polarity Predominance or MPP,
usually present with their first episode as mania,
so it's obvious from the start
that this is not unipolar depression.
People with mania predominance
also tend to have their first episode at a younger age,
like late teens or early 20's,
and tend to have more psychotic symptoms
with their mania or depression.
The main psychotic symptom is delusions.
If it's a manic episode, the delusions tend to be grandiose
or religious - going naked in public while manic is a thing.
If you're in the depressed state,
the delusions tend to be more persecutory
like someone is out to get you.
A person with mania predominance
can have the classic pattern of mania
followed by a depression crash or back-to-back mania.
Even though mania tends to be more destructive,
creating a devastating path of bad decisions
and negative consequences, from a treatment standpoint,
mania is much easier to treat than depression.
Why?
Because the antipsychotics we use as mood stabilizers
are much better at slowing down mania
than they are at lifting someone out of a depression.
So being manic is scary,
because of the unpredictability of your behavior,
but the good side is if you stay
in contact with your doctor,
and have family or friends keeping an eye on you,
you can catch the symptoms
before they spiral out of control,
making the treatment outcomes better
for people with the mania predominance.
Now, there are people who don't have a predominance
of one pole over the other.
You may have the more classic pattern
of alternating episodes.
You can have depression, then mania,
then an interval with neither,
and that interval can be months to years,
and then you get depression again, and the cycle repeats.
Why does it matter to know all of this?
One way it can help is in your medication choice.
There's some research and development
that looks at rating medications
by their tendency to do better with mania versus depression,
and developing an algorithm, which you can use
to choose the medication
based on the person's polarity predominance.
This polarity index is called
isn't ready for general use yet.
It still needs some more studies
to show that it works consistently,
but we do have some ideas about which medications
are supposed to work better for bipolar depression
whether you're depression predominant or not.
Most of the medications work well for mania,
but it's the depressed phased and mixed symptoms
that are more of a problem.
I have a handy guide that tells you what medications
are FDA-approved for what phase of the illness.
I'll have a link in the description
where you can download it,
but I'll go ahead and say for now
that Quetiapine or Seroquel is the brand name, Vraylar,
Latuda, and the new CAPLYTA are FDA-approved
for bipolar depression, and Lamotrigine
is not FDA-approved for bipolar depression,
but in practice, it's used a lot for this purpose.
So if you are depression predominant,
you may do better on one of these meds.
For the person who is mania predominant,
you should be especially careful
about taking an antidepressant
when you slip into depression.
Remember I said that some people can get by
with a little bit of an antidepressant
added to their mood stabilizer
to get them out of depression?
That's probably not you.
If you are mostly manic with infrequent depressive episodes,
an antidepressant is more likely to flip you into mania,
a mixed episode, or send you rapid cycling.
What can you do then if you get depressed?
Your doctor can add another mood stabilizer
or add lithium if you're lithium-responsive.
Not everyone is, I have a video talking about that,
called "Classic vs Atypical Bipolar Disorder".
Another thing that you can do is light therapy.
There's a modified protocol for bipolar disorder
and I have a video on that too.
If your bipolar disorder is a new diagnosis
and you don't have enough of a pattern
to establish a predominance,
it's time to keep a mood journal.
It doesn't have to be anything fancy.
You don't need to journal your mood every day.
You just need to keep up with your mood episodes.
If you had a depressive episode in March, 2020,
write it down and write down how long it lasted.
You don't need to be exact.
Was it weeks, or months, or years long?
Then the next time you have another episode
and we're talking about symptoms that last
at least two weeks for depression or a week for mania,
write down the month and the year that you have that.
Then at some point, you can get a bird's eye view
of how many episodes you have in a year,
which pole you were,
and how long your episodes typically last.
Now I realize episodes are painful,
and this is probably not something you want to keep up with,
but you don't need to meditate over it.
You just need to note it for reference later.
If you change doctors, this kind of information
will be super helpful for a smooth transition,
and if there's a pattern to your episodes,
the information can help inform your doctor
of what medication to prescribe
if you're not responding well to your current regimen.
Take a look at my bipolar playlist
for more on bipolar disorder,
and if you like having written information,
check out my Bipolar Handbook.
It's one of the items in my merch store.
Thanks for watching.
See you next time.