Even though a manic episode is needed to make the diagnosis of bipolar disorder, most people with bipolar also experience periods of depression. In fact, bipolar depressive episodes typically occur more frequently and last longer than mania.
Depressive episodes often present long before manic ones do. Before treating depression, the doctor tries to assess the risk that someone will eventually develop mania, which is important because antidepressants alone can sometimes trigger manic symptoms if someone's brain is wired for bipolar disorder.
Additionally, the treatment for bipolar depression differs from that for unipolar depression, and research suggests that they're different in their underlying brain changes. Without clear-cut mania, however, differentiating bipolar depression from unipolar depression is difficult even for the most experienced psychiatrists.
Sorting out depression in children and teens
Depression in children and teens can be especially difficult to sort out. People who develop depression early in life have a higher risk of developing bipolar disorder than people who experience depression at a later age; still, most kids who suffer from depression don't develop bipolar disorder. To sort out the risks of your child having bipolar disorder, her doctor may explore some of the following warning signs:
Repeat depressive episodes: A kid who experiences numerous episodes of depression is a more likely candidate for an eventual bipolar diagnosis. If the episodes are brief (three months or less), the risk increases.
Family history: Having a first-degree relative, such as a parent or sibling, with bipolar disorder increases the risk of developing bipolar disorder by 5 to 10 percent.
Response to antidepressants: How someone responds to antidepressants is suggestive of, but not part of, the diagnostic criteria for bipolar disorder. Any of the following responses to antidepressants may lead a doctor to suspect the possibility of bipolar disorder:
Mania or hypomania occurs. (Note that people can become manic or agitated on antidepressants without having bipolar disorder, but if the mania persists after the antidepressants are removed, then this is part of the diagnostic criteria for mania/bipolar disorder.)
Antidepressants don't work.
Antidepressants work initially but then stop working, even after dose increases and trials of different antidepressants.
A larger-than-life temperament: People with baseline hyperthymic personalities are considered a high bipolar risk. Hyperthymic is a medical term for high energy — meaning extremely outgoing and active — often highly confident, and sometimes seen as arrogant or narcissistic.
Repeat depressions, a family history of bipolar disorder, certain responses to antidepressants, and a hyperthymic personality aren't diagnostic for bipolar disorder; rather, you should consider them red flags. If your child's doctor spots several of these warning signs, she may develop a different treatment plan than she would for a kid without the possible bipolar indicators.
Whether it's unipolar or bipolar, child and adolescent depression is a condition that tragically results in one of the leading causes of death in teenagers: suicide. Depression is a serious medical condition that requires appropriate evaluation and care.
Recognizing depression in your child
Depression can be tricky to spot, particularly in teens who already seem moody and impulsive. Depressed kids and teens can appear angry, bored, or withdrawn rather than sad and dejected. In children and adolescents, irritability, instead of sadness, can be the major mood state in depression. Because irritability is also often prominent in manic episodes, sorting out mood symptoms in kids can be slippery.
In order to determine whether your child is being dramatic or is sinking into a serious depression, look for the following signs:
Persistent changes in function: Everybody has good and bad days — sometimes even a few in a row, but when your child or adolescent begins to experience extended periods of time when she's not herself, you need to pay attention. Explore further any significant changes in grades, friends, activities, energy, and enthusiasm that go on for more than a couple of weeks.
Any self-harm or references to suicide: These are critical red flags that you must respond to immediately. Even if you think your child just wants attention or is trying to manipulate you, the fact that she's using suicide or self-injury as her tool is a real problem.
Always take threats of suicide seriously. Don't try on your own to determine whether your child really means it. Involve a professional immediately.
Withdrawal: Kids like their personal space, and adolescents, in particular, spend plenty of time in their rooms. But kids who hardly leave their rooms, lose interest in spending time with friends, or drop out of activities are showing signs of depression. This behavior can happen gradually and be easily overlooked.
Sleep/energy shifts: Kids change their sleep patterns throughout development. Teenagers typically develop a need to stay up late and sleep later into the day. However, a kid who changes her patterns and starts sleeping a lot more or a lot less than usual may be depressed. If your child's energy levels seem to drop and not rebound after a couple of weeks, schedule a medical exam. If the doctor finds no other medical cause, depression may be a possibility.
Substance use: Drinking and marijuana use seem to be ubiquitous in high schools nowadays. Keeping kids away from these experiences is a difficult challenge, but a kid who uses drugs and alcohol regularly or significantly increases her use may be self-medicating. Don't convince yourself that all kids do it. If your child gets high or drunk most weekends, you need to look into it. Even if depression isn't present, substance abuse in a teenager is a big problem and needs to be addressed as early as possible.