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Chapter 5 Getting a Psychiatric Evaluation and Treatment Plan

In This Chapter

Tracking down a qualified psychiatrist
Preparing for your first meeting
Sailing through your psychiatric evaluation and diagnosis
Obtaining a treatment plan that works for you

The bipolar tempest not only rocks your boat, but also washes the captain overboard. Your rational mind flails in the waves, and nobody on deck has the wherewithal to throw it a lifesaver. You need someone on the outside to intervene. You need a psychiatrist.

A qualified psychiatrist can help you reset your rudder and steer your ship through the surrounding turbulence. She can explain what happened during your most recent mood episode, provide an objective evaluation of your psychiatric condition, offer one or more possible diagnoses, and develop a personalized treatment plan for you. Your evaluation, diagnosis, and treatment plan chart the course for your recovery, and your psychiatrist’s continued guidance helps you stay the course for years to come.

Because your psychiatrist plays such a key role in your evaluation, recovery, and continued stability, this chapter offers advice on finding a qualified psychiatrist who makes you feel comfortable and confident. We show you what you can do to help your psychiatrist develop an accurate assessment of your current condition and psychiatric needs. We also provide a list of items you should bring to your first appointment and a few ideas on how to keep your relationship with your psychiatrist in good working order so you don’t rock the boat.

Finding Professional Help

Most people are happy to tell you all about their favorite doctors or healers; they eagerly share the names of their bone doctors, lung doctors, or gynecologists. But if you ask someone for the name of a good psychiatrist, you can feel the temperature of the room drop. Unlike plastic surgeons, psychiatrists don’t advertise on billboards: “Depression Lift. Mood Augmentation. Payment Plans Available!” You can flip through the phone book, but don’t expect it to steer you in the direction of a bipolar specialist; all psychiatrists are pretty much lumped together.

Is finding a qualified psychiatrist a hit-or-miss proposition? Not exactly. You just need to do a little homework, remain persistent, and be willing to test-drive a few models until you find the one that’s right for you. In this section, you find suggestions on where to start your search.

Remember: After you identify a psychiatrist, your journey is just beginning. The evaluation process takes time, and your treatments may require lengthy adjustment periods. If you’re in a crisis, your doctor is likely to treat you more aggressively, possibly admitting you to a hospital. But even in a hospital, the process of being worked up (having a doctor piece together your history, his observations, and test results to arrive at a diagnosis) and developing a treatment plan can be achingly slow.

Ask your family doctor

When you stump your doctor with an illness, he has a list of specialists to whom he can refer you. “Weird heart murmur? See Dr. Pulmonic, the cardiologist.” “Skin discoloration? Here’s a referral to Dr. Rasho, the dermatologist.” The same is true of psychiatrists. Your family doctor, or internist, probably knows at least one psychiatrist in his circle of colleagues whom he can recommend–a psychiatrist your doctor has worked with in the past who has a successful track record. When you report mood-related symptoms that your doctor can’t trace to a medical cause, he may recommend that you see a psychiatrist. When he does, ask for names.

If you’re a woman, and your gynecologist fills the role as your primary care physician (a common arrangement), ask her for a psychiatric referral. The two fields often team up on diagnoses such as PMS and postpartum depression. She can give you some names of psychiatrists with whom she likes to work.

Call your insurance company

Insurance companies have contracts with certain doctors whom they refer to as “preferred providers.” These doctors have agreed to the insurance company’s rates, making you responsible only for your co-pay. If you go to a doctor who’s not on this list, you may have to pay the full fee, so finding a psychiatrist “in network” makes sense for financial reasons and because the psychiatrist probably works with other doctors and hospitals in your network.

Tip: When looking at a preferred-provider list from your insurance company, you can ask for more information about the doctors. You can ask whether a doctor is board certified; request information about his level of experience; and check on any areas of subspecialty, such as doctors who deal with mood disorders. If you can’t find a doctor qualified to care for your type of illness, you can appeal to your insurance company to cover a doctor outside the plan so you can get appropriate care without paying extra.

Pick your therapist’s brain

Treatment need not begin with your family doctor or psychiatrist. You may already be working with a therapist, likely a psychologist or social worker, for when your moods hit a critical point. If you’re currently seeing a therapist you like, ask her for a referral. She should be familiar with psychiatrists in your area, possibly within the same office, and she should know which people she works with most effectively.

Successful treatment almost always demands a consistent, coordinated combination of medicine and therapy, so you want a treatment duo who work well as a team. If your therapist and psychiatrist graduated from different schools of thought, they may be unwilling and unable to provide the integrated treatment that you deserve. By obtaining a referral from your therapist, you increase your odds of building a treatment team with a unified vision.

Tip: If your therapist and psychiatrist work out of the same office, the proximity often enhances communication. They can share notes and records without the extra work; added costs; and delays inherent in phones, shipping, and fax machines.

Go online

The Internet brings power and information, but it can also bring misinformation and fraud. When searching online for names of psychiatrists, use established, professional Web sites provided by a local medical society or a specialty society, including the following:

American Psychiatric Association (www.psych.org)
Depression and Bipolar Support Alliance (www.dbsalliance.org)
National Institute of Mental Health (www.nimh.nih.gov)

The DBSA site, which is consumer driven, provides a list of recommended professionals (by people being treated for bipolar disorder) and is packed with useful information for people suffering from depression and mania.

University, hospital, and medical school sites also have physician search tools, and they usually list each doctor’s subspecialty. By checking subspecialties, you may be able to find someone who’s studying bipolar disorder in her research.

Warning: If you search more broadly and find other sites about mood disorders and doctors, be sure to get additional references about the doctor or clinic before you make an appointment. The Internet has its share of misinformation. If you’re unsure whether a doctor who looks good to you is legitimate, double-check the doctor’s licensing and complaint history with your local medical society, which you can do for any doctor you consider seeing.

Consult your support group

As your symptoms develop, you may seek help from a support group–a therapy or self-help group, a 12-step program, or an advocacy group. Maybe a loved one, a judge, or a therapist recommends or demands that you attend anger management or parenting groups. These settings are gold mines of information about local doctors. Seasoned veterans freely vent about doctors they adore and those they despise. Ask around and expect an earful!

Don’t limit your search to official support groups. Consult your personal support group as well–your brain trust–the people who provide daily guidance and care and who know you most intimately. If they have any connections with psychiatrists, they can make recommendations with your temperament and needs in mind.

What to Look for in a Psychiatrist

When you’re shopping for a psychiatrist, you may begin to wonder who’s doing the shopping. Everyone is grilling you with questions. When do you get to ask questions and obtain the information you need to make an educated choice? The answer to that question is “The sooner, the better.”

Tip: Chapter 19 provides a list of 10 questions to ask a psychiatrist or therapist. Before your first visit, review those questions, and prepare yourself. If you’re not the assertive type, ask a friend or relative who’s a little pushier to join you. Bringing along a trusted ally, especially for the first visit, can make all the difference in getting the information you need and walking away with a good sense of how this doctor may work for you. Your support person can also provide valuable information to the doctor–details you may forget or consider too insignificant to mention.

When scouting for a psychiatrist, use the following criteria to guide your selection:

Experience: Experience in treating mood disorders usually ensures a more accurate diagnosis and the most effective and current treatments. Be sure to ask the psychiatrist how much experience she has had in treating bipolar disorder.
Sensitivity: Your psychiatrist should be a team player who accepts your input and adjusts your treatments accordingly.
Willingness to communicate: Your psychiatrist should not only prescribe medications, but also explain their purposes and possible side effects.
Availability: Your psychiatrist may need to adjust your diagnosis and medications frequently, especially in the early stages of treatment.
Affordability: Is this doctor included in your insurance plan? Do the charges for office visits fit in your budget? Does the doctor offer a payment plan?

Remember: Your doctor should be board certified in psychiatry. This means that she has passed a rigorous set of exams, indicating her mastery of the specialty of psychiatry. The American Board of Psychiatry and Neurology is one of many specialty boards that certify doctors as competent within a specialty. Doctors can have licenses to practice medicine, but they may not be board certified in a specialty. Doctors without board certification may have the required skills, but the designation makes it much easier for you to verify their credentials. Dating back to the mid-1990s, psychiatrists must retest for their board certifications every 10 years to ensure that they keep up with all the rapid changes in the field.

What to Bring to Your First Meeting

If you’ve never been to a psychiatrist, your imagination may cook up a vision, using ingredients from old movies: you lying on a couch and relating stories from your childhood to an old man who sits in a chair beside you and jots down notes while he strokes his beard.

Reality paints a different portrait: you sitting on a comfortable chair or couch, describing your symptoms to a professional man or woman who sits in a chair across from you or behind a desk and peppers you with questions about your current behaviors and feelings while jotting down notes.

During your first meeting, your psychiatrist tries to write your story in medical terms that accurately describe an illness such as bipolar disorder. She needs a great deal of information about you, so she must ask a string of personal questions. She can’t get inside your head to see what you think and feel, so she relies on the following information to guide her diagnosis:

Objective information: Your psychiatrist’s observations of your appearance and reactions to the interview, along with your report of recent behaviors.
Subjective information: The information and details you provide about how you feel and what you’re thinking.

Tip: Your best shot at receiving an accurate diagnosis depends on your honesty and openness and on your ability to clearly describe your thoughts and feelings. If you withhold important information because you’re embarrassed or for any other reason, you can’t expect your psychiatrist to paint an accurate diagnostic portrait.

To prepare for your evaluation, you should collect the information we describe in this section, either in your head or on paper, and get ready to share the intimate details.

Can’t you just test me?

Unfortunately, the technology to test for bipolar disorder doesn’t yet exist, for several reasons: Bipolar disorder is probably a collection of different conditions; the brain changes are at microscopic levels that scans have a hard time detecting; and blood chemistry doesn’t accurately depict brain chemistry. The future holds out hope in the form of some new and improved detection tools. Some innovations currently brewing include the following:

A functional MRI scan looks at changes in brain chemistry–how active certain parts of your brain are. This technology may someday be able to detect consistent differences between brains with bipolar disorder and those without.
Genetic testing looks for certain genes associated with the brain-chemistry changes present in bipolar disorder. Particular proteins and patterns of proteins and enzymes may form the fingerprint of bipolar disorder, and detecting the genes that regulate these proteins could eventually help in identifying the disorder.
Neuropsychological tests (paper-and-pencil testing) may help map patterns of attention, memory, and information processing (executive function) that appear to be associated with bipolar disorder. These tests may eventually aid in the early identification of bipolar disorder in children with attention and behavioral problems.

Why you (or others) think you need help

The first thing your doctor wants to know is your chief complaint: What’s going on that prompted you to seek a psychiatric evaluation? This is a story that starts at the end and then goes back to fill in the details. Perhaps you’ve been bedridden for days, raging for weeks, watching your mood swings chip away at your marriage, spending extravagantly, feeling completely overwhelmed by everything on your to-do list, or getting into arguments with friends and relatives. If someone recommended that you see a psychiatrist or therapist, explain why that person thinks you need help.

More information, please!

Your chief complaint simply states the problem. After you establish the problem, your psychiatrist can start collecting details about your emotional life and your behavior patterns over the years. She may refer to these details as the history of present illness or review of systems (organ systems and brain systems). Through this systematic information-gathering approach, your psychiatrist attempts to understand the pattern of psychiatric symptoms that play a role in your condition. To gather a list of symptoms, your psychiatrist is likely to ask many of the following questions:

Depression-related questions: How sad do you get and for how long? Do you feel hopeless or helpless? Do you think about death and dying? Do you think about killing yourself? Have you ever tried to kill yourself? Do you enjoy things anymore? Can you concentrate? Are you tired all the time?
Mania-related questions: How happy or angry do you get and for how long? Do you have periods of high energy and productivity? Have you gotten into trouble during those times by spending money, having an affair, or “borrowing” money from your employer? Do you have times when you feel like you’re the best at everything?
General questions on your thought processes: How’s your thinking? Do your thoughts feel slow or hyperactive? Do you feel as though you can’t think clearly? Does your brain play tricks on you–hearing voices, believing you have magical powers, or thinking people want to harm you?
Questions about anxieties and compulsive behaviors: How much do you worry about things? Have you ever had a panic attack? Do you have unwanted thoughts that don’t go away or illogical behaviors you can’t stop doing? Do you freeze in social situations or avoid them altogether?
Mental health history questions: What’s your psychiatric history? Have you ever been hospitalized? Have you ever been on medications? Have you seen a therapist at some time in your life?
Questions about your life in the past: What was your childhood like? How did you do in school? How did you relate to other kids? Did you have close friends? Did you experience any depression or manic symptoms as a teenager or child?
Questions about your life now: What’s your life like now? Do you work? How’s work going? How’s your marriage/love life? How’s sex going for you? How are things with your kids, your parents, or your siblings? Do you have hobbies? Do you exercise?

Remember: As you can tell from these questions, the best way to respond is with a significant other who can offer some details that you may not remember or see in yourself. If your significant other or another family member is willing, and you’re comfortable with the person’s being in the office with you, the two of you can provide more valuable information more quickly and completely than if you go alone.

Medical history

Have you seen your primary care physician about your chief complaint? If you haven’t, refer to Chapter 4 for a better understanding of why this is such an important first step. After you explore that avenue, provide your psychiatrist with the test results and recommendation from your doctor.

Although your primary care physician probably conducted a thorough physical exam and interview, you can expect your psychiatrist to ask several questions about your current physical condition as well. Any headaches, weakness, or dizziness? Diabetes or heart disease? History of stroke or cancer? Eye problems (such as glaucoma)? Have you had any surgeries? Allergic reactions to medications? How about your kidneys, liver, and lungs?

Remember: Your psychiatrist needs your medical history for two purposes: to help rule out other physical conditions that may be causing or aggravating your symptoms and to determine the safest, most effective medications to prescribe, if you need medication.

Family history

When you start shaking the family tree of a person who exhibits classic bipolar symptoms, skeletons often rain down from the branches. These skeletons can help your psychiatrist do the following:

Simplify the diagnosis: If one of the skeletons happens to be a first-degree relative (immediate family member) with a mood disorder, a schizophrenia diagnosis, or a history of suicide, your risk of having a mood disorder is significantly higher (see Chapter 2). Second-degree relatives (uncles, aunts, cousins) count, too, but to a lesser degree.
Differentiate between unipolar and bipolar depression: If you’re experiencing depression but have a family history of mania or schizophrenia, you may have bipolar disorder without yet experiencing mania or hypomania. Prescribing an antidepressant alone to a person with the potential of bipolar carries a high risk of inducing mania. If bipolar disorder appears in your family history, your psychiatrist is much more likely to start with a mood stabilizer, with or without the addition of an antidepressant, rather than with an antidepressant by itself.
Determine the most effective medications: If a particular medication or therapy has effectively treated one of your first-degree relatives, it’s more likely to effectively treat your similar symptoms.

Remember: Following are a few points to keep in mind regarding your family history:

You may not have a formal diagnosis for people in your family–especially in previous generations. But if someone in the family showed serious behavioral quirks–never left the house, drank or used pills excessively, or kept tinfoil on the windows to keep out the aliens–that’s worth mentioning.

Don’t limit your family history to diagnoses of bipolar disorder. Report all psychiatric problems: schizophrenia, depression, anxiety disorders, panic attacks, extreme mood swings, and so on. Different disorders often share common genetic factors.

Your doctor will also be curious about any suicides in the family. The risk of suicide seems to run genetically, even separate from bipolar disorder and depression. Substance abuse in a relative can hint at underlying mood or anxiety disorders. Substance abuse and mood disorders commonly occur in family groupings.

List of legal and . . . yes . . . illegal drugs

Your psychiatrist needs to know about all the chemicals, dietary supplements, and herbs that you pop and pour into your body. You already know that you need to hand over a list of prescription medications, but don’t overlook the other stuff, including the following:

Over-the-counter medications you take regularly
Vitamins
Herbs
Alcohol
Caffeine
Energizer beverages, powders, or pills
Diet medications or herbs
Nicotine
Amphetamines or other stimulants or controlled substances
Marijuana, cocaine, ecstasy, hallucinogens, narcotics, or other illicit drugs

Remember: If you’re using illicit drugs, tell your doctor. These substances drastically affect your emotions and behavior, and this information is critical in your psychiatric evaluation. Embarrassment and worry about being “caught” or “found out” have no place here. Your psychiatrist won’t report your drug use to anyone unless you pose a risk to someone else. Brutal honesty is the only workable policy.

Warning: Hiding drug or alcohol use from your doctor can be fatal. Don’t do it. Muster up all your courage, ditch your shame, and spill your guts. You aid in your recovery, and you just may save your life.

Sleep log (or sleepless log)

Whether you’re sleepless in Seattle or drowsy in Denver, your doctor needs to know about it. Sleep changes and energy patterns are core biological markers in bipolar disorder; they provide important clues that tell you and your doctor when you need help. Report any of the following:

Excessive need for sleep
Inability to feel rested even after sleeping for a long time
Persistent fatigue
Little or no need for sleep
Significant changes in sleep patterns

Remember: Note your sleep cycles and energy levels. Being awake all night and dragging around the next day is a different story from having a three-day wakeful jag and still feeling perky.

Tip: Remembering how well you sleep from one week to the next can be a challenge for anyone, so write it down. Also, ask your significant other for help; he or she may have an entirely different read on how well or poorly you sleep.

Arriving at a Diagnosis

You spilled your guts, confessed your sins, and admitted to doing things that could have landed you in jail. All you want in return are clear answers to two simple questions: “What do I have?” and “How do I get rid of it?” You, your friends, and your significant other have slogged through months of unexplained self-destructive and unbearable symptoms, and you need an answer. Unfortunately, unraveling the mystery may take some time.

Evaluating your symptoms

To arrive at a diagnosis, your doctor compares your symptoms to criteria specified in the DSM-IV–the Diagnostic and Statistical Manual of Mental Disorders, Version 4. DSM-IV is the bible of psychiatry that describes various syndromes and conditions and the symptoms that must be present to establish a particular diagnosis.

What symptoms are characteristic of bipolar disorder? Here are some highlights your doctor looks for:

Evidence of mania: You experience a week or more of high energy, excessively happy or angry moods, little need for sleep, excessive activity and pleasure seeking, little judgment or impulse control, grandiose thinking and behaviors, and racing thoughts (to the degree that they create problems in your life).
Evidence of major depression: You experience two weeks or more of sad mood, low energy, decreased enjoyment of things, poor concentration, low activity and low productivity, thoughts of death and suicide, excessive feelings of guilt or bad feelings about yourself, and slowed thinking (to the degree that they create problems in your life).
Evidence of hypomania: Consisting of an elevated mood that lasts four days, hypomania is a “light” version of mania and doesn’t create so many problems in function, but it can be difficult to live with.
Presence of psychosis: Psychosis can go along with either “pole”: depression or mania. It can include disorganized thinking, paranoia, delusional thinking (significant distortions of reality), or hearing voices.
Presence of mixed states: Mixed states are combination states that meet full criteria for mania (or hypomania) and depression together.

Climbing your family tree

Because much of the risk for bipolar disorder comes from inherited genetic vulnerabilities, family history is an important piece of the diagnostic puzzle. Although the DSM-IV doesn’t list family history as one of the diagnostic criteria, if the bipolar diagnosis seems plausible but a little fuzzy, a strong family history may tip the scales.

Considering other causes

After the picture of your mood symptoms has developed, and your family history is on the table, your psychiatrist must look closely at other symptoms and problems that you’re having. This differential diagnosis allows her to explore all the possible causes and to determine if she needs to address additional diagnoses. The types of symptoms most important at this point are the following:

Substance abuse can mimic mood disorders or can occur with and exacerbate mania or depression.
Medical conditions — such as thyroid disorder or other hormone imbalances, infections, autoimmune disorders, cancers, heart disease, or stroke — can produce similar symptoms.
Anxiety disorders can sometimes look like mood disorders. Panic attacks may look like brief manic episodes, for example, and they’re often comorbid (co-occurring) with bipolar disorder.
Psychosis, which may be a symptom of mania or depression but also of schizophrenia or schizoaffective disorder, must be addressed in order to rule out those disorders.
Attention Deficit Hyperactivity Disorder seems to overlap with bipolar disorder in many people and should be identified when it does. Alternatively, the high energy of mania can sometimes be confused with ADHD, and the similarity can blur the diagnosis, especially in young people.

When diagnoses converge

Kevin went to see his doctor after dropping out of college for the third time. Every time he tried to go to class, he would shrink into the back row and spend the whole time worrying that people were thinking about how stupid he was. He stopped going to class and then dropped out. After his latest failure, he stayed in his apartment all day and didn’t answer the phone. He felt like a freak and could barely drag himself out of bed. All he did was sleep.

While relating his history to his doctor, he recalled that he had survived high school only by borrowing friends’ notes, because he hardly ever went to class. He also confessed that during his senior year, he started drinking a lot, and he got into trouble with his parents for stealing money from them and spending it with his friends. Senior year was the only time in his life that he got into trouble with the law–after he and his friends stole his parents’ car and took a midnight road trip to check out a bar two states away. He told the doctor that he slept very little that year–he spent his nights on the Internet and practicing his guitar and then stayed up the following day. He described it as the “happiest time” of his life, but he had almost failed all his classes. He noted that his mom had a drinking problem and seemed to have some pretty depressed times, but she had never been diagnosed with a mood disorder.

The doctor arrived at a diagnosis of Bipolar I, along with Social Anxiety Disorder (see the next section for more on the different types of bipolar disorder). Over time, as Kevin stabilized with his mood and anxiety disorder, he tried to go back to school and discovered he had terrible trouble paying attention and focusing. Eventually, the doctor added medication for ADHD. Given Kevin’s family history, the doctor also counseled him that he was at high risk for alcoholism. Stopping drinking became an ongoing challenge for Kevin, but he remained vigilant. He returned to school–only one class to start–and found success there. Although Kevin continues to struggle, he’s gradually leaving the past behind and learning to effectively deal with his dual diagnosis.

Receiving the diagnosis

You’ve been poked and prodded, examined and cross-examined. Your psychiatrist has even rummaged through your family tree. Now you want to know: What is it? What do you have that’s causing you so much discomfort and misery? This section reveals the most common bipolar diagnoses.

Typecasting your illness

If you’re “lucky,” you step right out of your psychiatrist’s office with a clear, textbook diagnosis. You have one of the following types of bipolar disorder:

Bipolar I is the classic form of bipolar disorder that includes clear-cut manic episodes, periods of major depression, and euthymic (even-mood) times in between. Bipolar I has been recognized for the longest time and has the most predictable course and response to treatment.
Bipolar II differs from I in that depressive episodes alternate with hypomanic periods rather than manic ones. This variety is often harder to identify, because hypomanic periods can be tricky to spot and may remain unreported. Its course is also more variable, and the response to treatment is less predictable.
Cyclothymic disorder is a more subdued version of bipolar disorder, characterized by depressive spells and hypomanic times that never have sufficient intensity or duration to meet full diagnostic measure. It has to be chronic–two years or more–and it must interrupt your life in some way.
Bipolar NOS is the “leftover” category, characterized by variations of cycling mood disorders that reflect episodes of mood problems that interfere with your life but don’t fulfill the complete diagnostic requirements.

For more information on each of these possible diagnoses, refer to Chapter 2.

If you’re not so lucky, and you don’t present textbook-variety symptoms, your diagnosis may be murky and tentative. Maybe you have an anxiety disorder with some depression, obsessive compulsive disorder with some characteristics of attention deficit disorder, or a touch of mania with paranoia. In other words, your diagnostic portrait may look more like an abstract painting. Your doctor may provide you with an initial diagnosis and then continue watching your progress over time to confirm, refute, or modify it.

Finding your place on the bipolar spectrum

Having four bipolar categories sure simplifies the diagnosis, but does this model jibe with reality? Not according to some experts in the field. Psychiatrists are beginning to find that the four categories are too limited; they fail to accommodate symptoms and patterns that don’t neatly fit into one of the four categories. A growing trend is to diagnose mood disorders on a sliding scale, or spectrum. You may hear of the bipolar spectrum or the unipolar depressive spectrum.

The purpose of the bipolar spectrum is to help identify the disorder in people who don’t exhibit classic symptoms–for example, a depressed bipolar sufferer who has never experienced hypomania or mania. Misdiagnosing this person with unipolar depression can be dangerous, because treatment with an antidepressant alone is likely to induce mania. By finding the person a place on the bipolar spectrum, the psychiatrist can begin treatment with a mood stabilizer and probably achieve better results.

Remember: Don’t be surprised if your diagnosis changes over time; symptoms commonly change over the course of the illness. You may be diagnosed with Bipolar II and then experience a full-blown manic episode that changes your diagnosis to Bipolar I. This doesn’t mean that your initial diagnosis was wrong–only that that course of your illness has changed.

Treating unipolar depression with mood stabilizers

Current scientific evidence suggests that people with recurrent, severe depressions are more like people who suffer from bipolar depression than they’re like people with single or infrequent episodes of unipolar depression. Some research has revealed a significant overlap between the family histories and treatment-response profiles of all patients with severe, cycling mood episodes, even if they experience only one pole (depression) instead of two poles (bipolar). (Frederick K. Goodwin, MD, former director of the National Institute of Mental Health, is a leader in this field of research.)

If the research proves true, the treatment recommendations for unipolar depression may change significantly. Traditionally, doctors treated most cases of unipolar depression with antidepressants. Now, doctors are becoming more cautious in their use of antidepressants. Psychiatrists will look closely for red flags, such as a family history of bipolar or particular patterns of the patient’s depression, to try to determine the risk of triggering agitation or mania in a depressed patient. If the doctor spots red flags, she may consider using a mood stabilizer or a potentially less irritating antidepressant as a first choice.

Gauging the severity of your illness

The severity of bipolar disorder varies from one person to the next. Some people may go for years without a major mood episode, whereas others cycle four or more times a year. A depressive episode can drag on for months or end in a matter of days. Some individuals have only mild depressions and hypomanic episodes that barely interfere with their ability to function. Determining the severity or predicting the overall course of the disorder is difficult, but the following factors clue you in to what you can expect:

The presence of psychosis commonly marks more severe mood episodes.
Early onset of the disorder, in childhood or adolescence in particular, often indicates increased severity and predicts a worsening of the mood episodes over time.
An increase in the frequency, duration, and intensity of mood swings over time often indicates that the disorder is more severe.
An early and full response to medication, such as lithium, often indicates a milder form of the disorder with a more positive prognosis over the course of your life.
Rapid cycling may indicate a type of bipolar disorder that may be more difficult to treat.

Remember: You and your doctor can and should discuss these factors. Although some factors may indicate a harsher outcome, no factor locks in your destiny. Stress management, lifestyle changes, and careful and comprehensive medical management over time can significantly diminish the severity of symptoms and improve the course of the disorder.

Pushing the Limits of Psychiatric Labels

Your reaction to your diagnosis depends on many factors, including but not limited to your personal experience with people who have bipolar disorder, your awareness of the science and information about bipolar disorder, the attitudes about mental illness you grew up with, and your recollections of Hollywood characters with “manic depression.” In the movies, people with bipolar disorder are wildly out of control; they’re either dangerous villains or pitiful victims. Psychiatrists are always weird and creepy, and the “cure” is magical and complete or a sadistic failure.

A host of social reactions to mental illness may influence your responses. How will people see you and judge you? Will your employer fire you? Will your landlord evict you? The questions swirl through your mind and spark panic. So what exactly is the point of the bipolar label? Why do you need this in your life, and what are its benefits and limitations? The following list provides some answers:

A diagnosis guides treatment decisions. Just like a diagnosis of diabetes tells the doctor to initiate a certain treatment regimen, a diagnosis of bipolar disorder triggers the planning process of medication and therapy choices.
A diagnosis lets you know what to expect over time. Although the doctor can’t see the future outcome of a complicated illness like bipolar disorder, he can anticipate certain risks and patterns you’re likely to encounter over the course of the illness and possibly help you avoid them.
A bipolar diagnosis doesn’t define you. You’re not bipolar; you have bipolar disorder. This is a huge difference, because language conveys powerful meanings. Always refer to your illness as something you’re managing, not as a label that identifies you.
You choose whether and with whom you want to share your diagnosis. Your doctor and therapist can’t reveal your condition to anyone unless you give them permission to do so. You can’t be fired or evicted based on your diagnosis, even if the word does get out. Your civil rights demand that you not be discriminated against because of the diagnosis.
Some people may judge you based on your diagnosis. Judgment is a risk that comes with the label. Your task is to remember that these people are uninformed and afraid. You may choose to advocate, educate, and inform sometimes, but in other situations you may choose to limit your interactions with these people and keep a healthy distance from them.
Your label places you in a community of people with similar concerns. You have opportunities for support and networking that will be invaluable over the years. People who are going through the same situation band together in many ways–formal and informal–to take care of one another and advocate for the group. Others have “been there”–you know that from your labels–and they “get it.”

Walking Out with a Treatment Plan

When you’re ready to leave the doctor’s office, you should have more than a diagnosis. You want to have a well-defined treatment plan that covers your immediate needs and future directions. Ask questions about anything in the plan that you don’t understand. Don’t be afraid to bring a written list of questions to ask your doctor. With all that goes on during your first few appointments, you may easily and understandably forget to express your most pressing concerns and ask your most important questions. Write down the treatment plan as your doctor describes it (if you have someone with you, this can be a job you assign).

Tip: Get several of your doctor’s business cards so that you can give them to other caregivers, such as your therapist, family doctor, and cardiologist. Nobody expects you to carry around contact information in your head–just keep it in your wallet or purse.

Your treatment plan should include the following:

Medication names, dosing schedules, potential side effects, and time frames for them to begin working (you should have some understanding of why your doctor chose these particular medicines for you at this time)
Any changes in your current medications–decreasing doses or changing times of medications you were taking before this visit, for example
A plan for therapy, including the recommended type of therapy, names and phone numbers of potential therapists, and/or consent forms for your psychiatrist to speak to your current therapist
Forms necessary for any blood tests, other medical consultations, or examinations that your psychiatrist recommends
Instructions on how to reach your doctor if you have a problem or emergency before the next visit
Information about how often you need to meet with the psychiatrist, how long the appointments will be, and how much the follow-up visits cost
(Optional) Names of support groups in your area or online resources or books that your doctor feels can help you

Tip: Psychiatrist appointments, particularly at times of the day that work for you, are hard to come by. Before you leave (or right after your visit, if you have to call the office to make the appointment), schedule a series of appointments for four to six months out. This gives you the appointments that you need at times you can get there without turning your life inside out. If you stabilize and need less frequent appointments, you can always cancel, as long as you let the doctor know well in advance.

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