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Countless number of patients and their family members have asked
me about manic–depression and major depression. “Is there any
difference?” “Are they one and the same?” “Is the treatment the
same?” And so on. Each time I encounter a chorus of questions
like these, I am enthused to provide answers.
You know why? Because the difference between these two disorders
is enormous. The difference does not lie on clinical
presentation alone. The treatment of these two disorders is
significantly distinct.
Let me begin by describing major depression (officially called
major depressive disorder). Major depression is a primary
psychiatric disorder characterized by the presence of either a
depressed mood or lack of interest to do usual activities
occurring on a daily basis for at least two weeks. Just like
other disorders, this illness has associated features such as
impairment in energy, appetite, sleep, concentration, and desire
to have sex.
In addition, patients afflicted with this disorder also suffer
from feelings of hopelessness and worthlessness. Tearfulness or
crying episodes and irritability are not uncommon. If left
untreated, patients get worse. They become socially withdrawn
and can’t go to work. Moreover, about 15% of depressed patients
become suicidal and occasionally, homicidal. Other patients
develop psychosis—hearing voices (hallucinations) or having
false beliefs (delusions) that people are out to get them.
What about manic-depression or bipolar disorder?
Manic-depression is a type of primary psychiatric disorder
characterized by the presence of major depression (as described
above) and episodes of mania that last for at least a week. When
mania is present, patients show signs opposite of clinical
depression. During the episode, patients show significant
euphoria or extreme irritability. In addition, patients become
talkative and loud.
Moreover, this type of patients doesn’t need a lot of sleep. At
night, they are very busy making phone calls, cleaning the
house, and starting new projects. Despite apparent lack of
sleep, they are still very energetic in the morning — ready to
establish new business endeavors. Because they believe that they
have special powers, they involve in unreasonable business deals
and unrealistic personal projects.
They also become hypersexual — wanting to have sex several times
a day. One–night stands can happen resulting in marital
conflict. Like depressed patients, manic patients develop
delusions (false beliefs). I know a manic patient who thinks
that he is the “Chosen One.” Another patient claims that the
President of USA and the Prime Minister of Canada ask for her
advice.
So the big difference between the two is the presence of mania.
This manic episode has treatment implications. In fact the
treatment of these disorders is completely different. While
major depression needs antidepressant, manic-depression requires
a mood stabilizer such as lithium and valproic acid. Recently,
new antipsychotics, for example risperidone, olanzapine, and
quetiapine, have been shown to be effective for acute mania.
In general, giving an antidepressant to manic–depressed patients
can make their condition worse because this medication can
precipitate a switch to manic episode. Although there are some
exceptions to the rule (extreme depression, lack of response to
mood stabilizers, among others), it is preferable to avoid
antidepressants among bipolar patients.
When considering the use of antidepressant in a depressed
bipolar patient, clinicians should combine the medication with a
mood stabilizer and should use an antidepressant (e.g.
bupropion) that has a low tendency to cause a switch to mania.
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