Janice was fifty-five years old, unemployed, and as her regular GP was retiring, she needed to find a new doctor. She presented as well-presented and colourfully dressed, agitated but cheerful. Janice said she had always suffered from anxiety and had tried numerous antidepressants over the years. She found none had worked well. At one point, when her marriage broke up ten years previously, she was admitted to a private psychiatric hospital for several weeks for what she described as an “agitated depression”; she said she had been suicidal but had not acted on the thoughts she had.
Janice had had extensive counselling over the years for anxiety and knew all the techniques that had been taught to help her relax, although they did not work well most of the time. She did not suffer frank panic attacks, but on occasions her anxiety was severe enough to disturb her sleep for many weeks at a time. She could not identify any specific precipitant during these episodes and distracted herself by keeping busy into the early hours of the morning. She never felt completely “normal”, except for after the births of her two children, when she recalled feeling full of energy and truly happy for many months. At these times, she recalls she still had anxiety, but said that this was more of a feeling of excited anticipation rather than distress. Relatives had commented on her spending a lot of money on the new babies after each birth, and in hindsight, Janice realised she was purchasing many things she already had for the children and did not need more of.
Janice was currently taking fluoxetine 20mg daily and was considering stopping this, as it was not working for her agitation. She did not drink alcohol and did not like taking benzodiazepines. She now wanted advice about her situation.
The new GP wondered if Janice’s presentation could be a form of type 1 bipolar disorder. She arranged a psychiatric review and Janice was trialled on quetiapine XR 50mg nocte. The fluoxetine was ceased. Janice found over the following few weeks that her sleeping pattern improved and she felt a bit calmer during the day.
There are two types of bipolar disorder, type 1 and type 2. The patient with type 1 bipolar disorder is more likely to develop psychoses and usually has significant manias and depressions, often requiring hospitalisation or intensive medical supervision. The main feature of type 2 bipolar disorder are the sustained and severe depressions that may require hospitalisation. These usually alternate with periods of hypomania, but the individual affected does not lose touch with reality. Unipolar depression is a main differential diagnosis, especially of type 2 bipolar disorder, and may also require hospitalisation, but the patient’s history will uncover no periods of significant psychosis, elation, excess energy or hypomania. Variations in presentation of bipolar types 1 and 2 are common and the correct diagnosis requires a detailed history from the patient. Each patient has an individual pattern of mood variation.
There are several features of Janice’s history that suggest type 1 bipolar disorder. She had tried many antidepressants and had not responded satisfactorily to any. There had been a prolonged hospitalisation for severe agitation and depression; anxiety disorders are present in approximately 50% of patients with bipolar disorder. In Janice’s case, the intermittently severe agitation was probably a form of hypomania, as suggested in her history by her keeping busy at night to distract herself. Another important point is that bipolar disorder often flares after childbirth. Typically, there is precipitated a post-partum depression, but mania and hypomania, as in Janice’s case, are also not uncommon. The correct diagnosis is vital for effective management, as patients respond best to mood stabilisers and antipsychotics rather than antidepressants. In fact, the use of antidepressants alone may trigger hypomania and mania, as may be occurring in Janice’s case. It is important for GPs to be aware that severe, sustained anxiety may be a presentation of bipolar disorder.
1. Black Dog Institute, When to suspect bipolar disorder, 31 July 2013