Panic, Depression, or Bipolar Disorder: Telling Them Apart

Depression, anxiety disorder, and bipolar disorder share a lot of ground when it comes to how they feel day to day, yet each one calls for its own treatment path. Jeanie Lerche Davis points out that mood disorders and their symptoms frequently blur into one another. Reports of depressive and anxious symptoms have climbed steadily across the last century or so, and the pressures of money, work, and home life keep rising. People describe feeling swamped, which is why depression and anxiety so often get reported side by side.

A panic attack tends to arrive fast. If four or more of these hit you suddenly, you may be having one: a spike of high anxiety (with a trigger or without one), a pounding heart, sweating, shaking, a smothering feeling or trouble catching your breath, general discomfort, nausea, dizziness or feeling faint, and a dread that you are losing control or going crazy.

Charles Goodstein, MD, a professor of psychiatry at New York University School of Medicine who keeps a clinical practice in Tenafly, New Jersey, says it is common to see both conditions at once. "It's very hard to find patients who are depressed who don't also have anxiety," he told WebMD. "It's equally hard to find people with anxiety who don't have some depression." He sees it constantly. Problems with money, relationships, and family stir up worry and sorrow, and those reactions are ordinary. They stop being ordinary, he explains, when the feelings grow so intense that they wreck a person's daily functioning and quality of life. At that point the very problems that set off the depression become almost impossible to untangle.

The National Institutes of Health lists the markers of depression: a lasting sense of sadness, anxiety, or emptiness; hopelessness or pessimism; guilt, worthlessness, or helplessness; a loss of interest in things that used to bring pleasure, sex included; trouble concentrating, recalling details, or deciding anything; sleep that goes wrong in either direction, whether insomnia, waking before dawn, or sleeping too much; thoughts of suicide or actual attempts; and physical aches, headaches, cramps, or digestive trouble that stick around even after treatment.

Other diagnoses, bipolar disorder among them, can be in play too. When depression is the diagnosis, the attention falls on low mood and the way depressive states drag down functioning. Anxiety disorder centers on relentless worry and panic. Bipolar disorder turns on fast, intense swings between moods. The overlap between the three is exactly what makes them tricky to separate.

On the manic side of bipolar, the NIH describes a stretch of feeling "high," unusually cheerful, or wired; speech that races and leaps from idea to idea; a pileup of new activities and projects; sleeping very little without feeling tired; an inflated sense of one's own abilities; and impulsive dives into pleasurable, high-risk behavior. The depressive side of bipolar mirrors ordinary depression: a long spell of sadness or hopelessness, loss of interest in things once enjoyed including sex, fatigue or a slowed-down feeling, trouble concentrating and deciding, shifts in eating and sleeping, and thoughts of death or suicide.

So does that mean antidepressants? Not necessarily. Davis urges people to speak frankly with their doctor so the diagnosis lands correctly. A physician needs an honest picture of the patient's inner life and has to run a full evaluation before deciding whether medication fits and which one. The doctor might schedule another look before writing any prescription, or send the patient to a psychiatrist. Once a medication starts, a follow-up (often at 30 days or three months) lets the doctor judge whether it is working and watch for side effects.

An antidepressant gets prescribed in a lot of these cases, and sometimes it is the wrong call. "Antidepressants are used to treat both anxiety disorders and depression. However, someone with bipolar disorder needs a different set of drugs, a mood stabilizer and antimanic medication," Fagiolini told WebMD. Mood stabilizers come in several forms, including lithium and anticonvulsants such as Depakote or Lamictal. The risk is real: "Giving an antidepressant to someone with bipolar disorder could trigger a manic episode," he says. A manic episode can turn dangerous because judgment collapses. People use more drugs, drive recklessly, burn through money, and have far more sex, often with no protection at all. Poor judgment drives up every kind of high-risk behavior.

Antidepressants themselves break into two main groups: tricyclics and selective serotonin reuptake inhibitors, the SSRIs. The Harvard mental health letter describes how they work: "Both drug classes act in brain pathways that regulate mood and the perception of pain. Tricyclics heighten the activity of the neurotransmitters norepinephrine and serotonin; SSRIs act more selectively on serotonin." Getting the choice right matters, because the wrong drug can worsen existing symptoms or bring on new ones. A person who feels worse and dislikes what the medication does to them often pushes back, refusing not only that prescription but other options too. Someone with bipolar disorder, by contrast, can hold steady in mood and behavior once they are on the right medication and taking it as directed.

Bipolar disorder is a long-term, chronic condition, so the National Institute of Mental Health recommends preventive treatment over the long haul. The institute finds that pairing medication with psychotherapy keeps the disorder in check best over time, and most psychiatrists and clinicians in practice agree. That combination applies to anxiety disorders, depression, and most psychiatric diagnoses as well. Medication settles the symptoms; therapy, using approaches such as Cognitive Behavioral therapy, works on the emotions, thought patterns, and behaviors feeding those symptoms. Therapy can also surface deeper issues and teach fresh coping skills.

Anyone noticing depressive, anxious, or mood-disorder symptoms, in themselves or someone close, should talk to a primary care physician. That doctor may prescribe medication or refer the person to a psychiatrist, a therapist, or both. What counts most is spotting that something is wrong and reaching out for professional help. - Kim B.

A quick aside on how people actually handle this. Most of us self-diagnose now, and a lot of us dodge the medical world whenever we can. The Affordable Care Act, Obamacare, made health insurance a requirement, but it never forced anyone to go seek care; it only required a way to help pay for it. The patient still has to show up and participate to get anything out of it. I am not here to explain Obamacare or sell its virtues. I am not qualified for that, and I am not sure anybody is. I doubt more than a dozen people in the country have read the entire piece of legislation. My worry is that, good intentions or not, it may be no better at getting people through the clinic door than whatever came before. That is a study somebody should run, with a real conversation about the results.

We are a generation that would sooner open WebMD than go see a Marcus Welby, MD. Talk shows hand out advice from doctors and psychologists. Infomercials chase our health and wellbeing, pushing the newest miracle pill or lotion that supposedly fixes everything, and most of them aim at problems we diagnosed ourselves. Notice how many are about libido? The pitch is always that once you sort out your libido, whatever the trouble is, you will finally be whole.