Q:  Recurrent Unipolar Depression

Hi Dr. Phelps,
I checked off that I have been diagnosed with bipolar disorder but that isn't actually the truth.  The truth is...I want to know if one can be bipolar without experiencing mania or hypomania.  I have had depression for about ten years (am now 26) and it always comes in cycles (though not regular cycles).  There are days when everything is fine, I am in a good mood and all is well.  Then there are days, weeks, or months, when depression hits hard.  I don't believe the good days are out of control and it is not only event related.  My maternal grandmother was bipolar I, and there is a history of depreesion on my dad's side too.  I am just wondering (long story short), can one be bipolar only in the range of depression and fine?  And if so, would you recommend a mood stabilizer?  I have been doing research on lamictal and am curious about that.  Any help you can offer would be greatly appreciated.  I thank you in advance,

Nicole
 

Dear Nicole -- 
Great question, and good that somehow you've found lamotrigine (Lamictal), because those two stories are related, and you've figured that out on your own. 

Here's how I explain this to my patients:  we know for sure there are people who only experience manias, no depressions.  I heard Dr. Tohen from Harvard say once it might be as much as 10% of people with bipolar I.  So, if someone can have only manias (and thus, obviously, merit a diagnosis of bipolar disorder), can someone have only depressions and also merit consideration of bipolar disorder (particularly if it's already been diagnosed in a relative)?

Or, to put it another way, maybe there are multiple variations of mood disorders (that much is pretty certain to be true) and one of them is a "recurrent unipolar" depression that might be pretty closely related to bipolar disorder, in that it has the same kind of irregular but repeated "cycling" that the more obvious bipolar folks go through, just lacking the hypo/mania side. 

Folks with this tend to reach me after they've been treated with antidepressants several times.  Often those work at first, often quite well, then "stop working" for subsequent episodes.  Sometimes the person gets irritable/anxious/insomnia on antidepressants right off; or sometimes that emerges later.  In most cases then, it's already been determined that antidepressants don't work (or keep working) by the time a person comes to see me.  Then, my job is pretty easy:  I get to wonder aloud about the way in which this might be more "bipolar"-like, as above, and we try some mood stabilizers with antidepressant potential.  And those are?

Lithium, for one; and lamotrigine.  Lamotrigine seems to have some particular value for people with this "recurrent unipolar" pattern.  We don't have good long term data on its effectiveness over time; it might still emerge that there's something bad about using it to prevent these episodes, such as we know lithium can do when used long term (e.g. some kidney problems, in people who take it for over a decade at pretty high doses).  But there are people who've been on it now for several years (for epilepsy) so presumably they'll find out first if there's a problem looming out there.  Lamotrigine, if your start is slowly enough, has much lower risk of the rash problem than we thought at first, and tends to produce few other side effects -- and thus is a good candidate option for you to evaluate with your doctor. 

Dr. Phelps

Published July, 2003