Why Lawyers Should Understand Complex Depressions
by James Phelps, M.D.

Editor’s Note: Dr. Phelps maintains a private practice of psychiatry in Corvallis Oregon.  His website at www.PsychEducation.org., has earned awards for ethics as well as education.  His father was a lawyer.  He is the author of the book Why Am I Still Depressed?

Statistically, lawyers are an unusual bunch. They all have advanced degrees. They are more likely than the average person to have high verbal skills, and high intelligence. They are considerably more likely to experience sleep deprivation due to work demands. For these reasons, lawyers need to understand a recent shift in the conceptualization of mood disorders.

The Spectrum of Depressive Disorders

Most mood experts now regard depression as a symptom found in a continuum of conditions ranging from "unipolar" to bipolar disorders. The latter were formerly lumped under the name "manic-depressive illness" but are now recognized to include multiple forms of mood disturbance. Of these mood variations, unipolar depression is the most straightforward. It responds frequently to psychotherapies and anti-depressant treatments. By contrast, bipolar depressions often do not respond to anti-depressants; or these medications may work for a time, and then stop working (so-called "Prozac Poop-out"). Occasionally, anti-depressants in such patients can even precipitate a full manic episode. More commonly, they create a "hypomanic" state in which manic symptoms are not so dramatic, yet cause serious problems, and remain undetected.

Until recently, psychiatric nomenclature emphasized only the two extremes of the mood continuum; major depression and bipolar disorder. In 1994, however, a version of bipolar disorder lacking full manic symptoms was characterized: Bipolar II. In this version, a milder form of manic symptoms-"hypomania"- was recognized. Patients with episodes of depression who also had subtle features of the high-energy side of bipolar disorder could now be recognized as "bipolar".

More recently, mood experts are recognizing yet more subtle forms of depression which over time manifest a course more similar to bipolar disorder than to major depression. Such intermediate forms of mood disorder, not fully "bipolar", yet clearly more complex than "unipolar" depression, have been termed Bipolar Spectrum Disorders. This term is not officially in the psychiatric nomenclature but is now widely used and recognized.

Lawyers need to understand this shift in the conceptualization of mood disorders, because they are probably at higher risk than the average person for having a more complex version of depression, more "bipolar". High levels of creativity and intelligence are prevalent traits among lawyers, as a group (with some notable exceptions, one might have to grant). These traits are also more common to people with bipolar disorder. Although to my knowledge, this potential connection has never been studied, it does seem more than plausible as a statistical risk factor. Moreover, sleep deprivation - an experience which occurs more frequently among lawyers than among many other occupations - is clearly associated with precipitating manic-side symptoms and mood swings.

As shown above, typical symptoms of depression do not identify what kind of mood problem a person is having. Bipolar depression and unipolar depression are nearly identical. But whereas the person with unipolar depression has only these symptoms, the person with bipolar has these symptoms and additional symptoms.

Unfortunately, many people with depression will reject the idea of "bipolar disorder" because they are sure they have never had mania, and are therefore certain that this diagnosis can not apply to them. They do not understand that manic symptoms can be present to a mild degree that does not interfere with their ability to function (hypomania). Interpret the following list of manic symptoms in that context:

Manic/Hypomanic Symptoms: DIGFAST

D Distractability

I Insomnia

G Grandiosity

F Flight of ideas

A Increased Activity

S Pressured Speech

T Thoughtlessness (impulsive, poor judgment)

But what should one make of a person whose depression includes just a hint of such features, below the threshold for intensity, or duration, or a number of symptoms? Does such a person not have bipolar disorder? If not, then what do they have? What label should be used for people whose symptoms place them in the middle of the mood spectrum?

Lawyers will be familiar with the dilemmas posed by dichotomizing a continuous variable - in this case, turning the full-color spectrum of mood disorders into a black and white symptom. According to the DSM-IV, a patient’s depression is either unipolar (major depression) or bipolar (bipolar disorder); no intermediate forms are allowed.

On the other hand, opening up the possibility of "sub-threshold" forms of mental illness is fraught with its own perils. In addition to the spectrum from unipolar to bipolar, a spectrum from "normal" to "diagnosable" rises from this Pandoran Box. Serious legal dilemmas spring forth as well; where along such a spectrum should "not guilty by reason of insanity" fall? As legal leaders are well aware, different states in our Union currently hold very different standards in this issue.

Similarly, significant controversy in psychiatry has attended the increasing use of the bipolar spectrum concept. Recognizing this increasing diagnostic disagreement, the International Society for Bipolar Disorders recently impaneled a committee on diagnosis to reveiw the current literature and issue recommendations for interim changes in the DSM (the next addition, DSM-V is underway, but will not arrive for several years yet). Acknowledging concern about "over diagnosis", the committee’s bipolar spectrum subgroup suggested a cautious expansion of the DSM-IV criteria for Bipolar Not Otherwise Specified ["BNOS"].

With this expansion of the ISBD recommended systematic assessment of "non-manic bipolar markers" to accompany the routine inventory of manic symptoms listed above. Non-manic bipolar markers are associated with bipolar outcomes but not compatible with the system of the DSM system, which is exclusively symptom-focused. These markers are often referred to as "soft signs" of bipolar disorder: they increase the likelihood that depression has a bipolar component, but do not in themselves make that diagnosis. However, informally, depression accompanied by many of these signs has been dubbed "soft bipolar disorder".

When a lawyer becomes depressed, she/he faces the same question that any person with such symptoms must address before beginning any form of treatment: Is this a unipolar, or a bipolar depression? Is there any history of irritability, sleep disturbance, or accelerated thought, speech or action? How many non-manic bipolar markers are present? Although relevant for anyone, these questions may be particularly important for lawyers. Because of the selection process for entering their profession, they may be more likely than the general population to have a bipolar component in any depression they might experience.

One of the first steps in diagnosis, for anyone, is to learn more about non-manic versions of bipolar disorder. Thus educated, people with depression can examine their own mood history, looking for episodes in which manic symptoms may have been present, as well a looking for "soft signs" in their personal histories. This can protect them against an insufficiently detailed inventory of these features by medical practitioners who may be rushed or insufficiently trained in this process.

To learn more about Bipolar II and soft bipolar disorders, see www.PsychEducation.org, a website written for patients and families seeking to learn more about "bipolar II" and "soft" bipolar disorders. It is extensively referenced. The site is free, and gathers no information about visitors. Although the author received honoraria from pharmaceutical companies for presentations on bipolar disorder, he believes the information presented on the website is not unduly influenced by these companies.