What about patients who present with a major depressive episode and have a strong history of bipolar disorder in their family but who have no discernable history of mania, hypomania, or even brief periods of elevated mood? These patients represent a difficult dilemma for psychiatrists. If, unbeknown to us, these patients are genotypically bipolar, we may risk pushing them into a manic episode if we treat them with antidepressants alone.3 On the other hand, one could argue that overtreatment with mood stabilizers would result if we gave all of these patients lithium(Drug information on lithium) (Eskalith) or divalproex (Depakote).
Although in DSM-IV there are no formal distinctions between a "major depressive episode" in the context of unipolar versus bipolar mood disorders, both research and clinical experience suggest otherwise: notwithstanding a great deal of variability, bipolar depression often does "look different." With the aim of helping the clinician recognize the hallmarks of a bipolar depressive bout, I have developed a mnemonic device that brings together several clinical, pharmacological, and familial "fingerprints" of bipolarity.5-12 The WHIPLASHED mnemonic (Table) has not yet been field-tested for its predictive or prescriptive validity—it simply represents a compendium of my own clinical experience and my synthesis of the research literature.
WHIPLASHED mnemonic for detection of bipolar depression9
Worse or "wired" when taking antidepressants. The patient often complains of feeling "antsy," unable to sleep, or more agitated on conventional antidepressants. Numerous failed antidepressant trials; apparent "tolerance" to antidepressants not overcome with increased dosage (pseudotolerance); and antidepressant-induced "switching" into mania or cycle acceleration may be reported.
Hypomania, hyperthymic temperament,* or mood swings by history. Periods of elevated mood or energy often do not fit formal DSM-IV criteria for hypomania; eg, some may last only a day or two. Mood lability in younger patients may be even more dramatic and poorly demarcated.
Irritable, hostile, or showing mixed features during the presenting depression. Some patients may show one or more hypomanic features (eg, racing thoughts) even while depressed.
Psychomotor retardation appears to be more common in bipolar I depression than in unipolar major depression; however, several studies note that psychomotor agitation is more common in bipolar II than in unipolar major depression.
Loaded family history, either for mood swings, frank bipolar disorder, or affective illness in general. A family history of comorbid mood disorder and alcohol(Drug information on alcohol)ism may also point toward bipolarity.
Abrupt onset and/or termination of depressive bouts, or relatively brief depressive episodes (less than 2 to 3 months). Some patients will also report a brief burst of increased energy or subthreshold hypomanic symptoms immediately before the onset of depression.
The author expresses his appreciation to Nassir Ghaemi, MD, and Jim Phelps, MD, for their suggested modifications of the original mnemonic. The present version represents the author's own conclusions, however.
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