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A caregiver's guide to how to properly identify the problem—and the best ways to help


Sometimes an illness isn't as apparent as it might be. There are no fevers or broken bones, no major physical traumas. But the pain is every bit as real. And the physical toll on the patient—and even the caregiver—may be just as dramatic as if someone were diagnosed with a physically obvious disease.

Clinical depression and bipolar disorder are two cases in point, with one often mistaken for the other. And, because we may not be as used to taking care of someone who needs psychological help, it's important to recognize their symptoms and understand their unique differences.

About Clinical Depression
There is a big difference between being sad due to grief, loss and/or a stressful situation and clinical depression. Sadness will lessen in time but clinical depression can continue for months—even years—on end. "In order to be ruled clinically depressed," says Joseph R. Calabrese, MD, professor of psychiatry and director of the Mood Disorders Program as well as co-director of the Bipolar Disorders Research Center at University Hospitals of Cleveland, Case Western Reserve University, "a person would have to feel disabling sadness most of the day, nearly every single day for a minimum of two weeks."

According to the Depression and Bipolar Support Alliance, it is important for both the caregiver and the person suffering to recognize that "depression is not a character flaw or sign of personal weakness. One can't just ‘snap out of it.'"

Mood disorders are complex and "there is much we don't know about what causes them," notes Elizabeth Saenger, PhD, assistant clinical professor of medical psychology (in psychiatry) at Columbia University Medical Center in New York. "Caregivers should remind their loved ones that they are not weak [or] irresponsible, but that something is physically wrong-for which there is help."

Symptoms of Depression
The American Psychiatric Association (APA) defines depression as "a serious medical illness that negatively affects how one feels, thinks and acts. It has a variety of symptoms but the most common are a deep feeling of sadness or a marked loss of interest or pleasure in activities." Other symptoms include:
  • Appetite change that results in non-dieting weight loss or weight gain
  • Insomnia or excessive sleeping
  • Loss of energy or increased fatigue
  • Restlessness or irritability
  • Feelings of worthlessness or inappropriate guilt
  • Difficulty thinking, concentrating or making decisions
  • Thoughts of death or suicide or attempts at suicide


About Bipolar Disorder
Bipolar disorder, unlike clinical depression, is marked by extreme changes in mood, thought, energy and behavior. These mood swings can last for hours, days, weeks or even months, according to the APA.

Symptoms of Bipolar Disorder
This disorder causes shifts in a person's mood, energy and ability to function. There are generally periods of normal mood behavior as well, but left untreated, those with bipolar disorder continue to experience these radical mood shifts. The periods of highs and lows are called episodes of mania and depression. The APA identifies these as characteristics of the manic and depressive phases:

Manic Phase

  • Feeling on top of the world. A sensation of sheer joy that not even a terrible tragedy can change
  • Sudden or extreme irritability or rage. While mania is often portrayed as a pleasurable experience, that is not so for many people with BD
  • Grandiose delusions. Individuals imagine they have connections withGod, celebrities or political leaders
  • A sense of invincibility. The person believes nothing can prevent him or her from accomplishing any task
  • Hyperactivity. Producing an unrealistically full schedule; inability to relax or sit still
  • Excessively risky behavior. Reckless driving, outlandish spending sprees, foolish business investments or out-of-character sexual behavior
  • Uncontrollable racing thoughts/rapid speech. Abrupt topic changes expressed in loud and increasingly incoherent, rapid speech
  • Less need for sleep


Depressed Phase

  • Intense sadness or despair. The person feels helpless, hopeless and worthless
  • No interest in activities once enjoyed
  • Loss of energy, fatigue
  • Sleep difficulties. Either sleeping too much or not at all
  • Appetite changes. A noticeable increase in appetite or a substantial weight loss unrelated to dieting
  • Difficulty concentrating, remembering, making decisions
  • Thoughts of death or suicide


Getting Help
The good news is that both conditions are treatable. The first step, which is often the hardest, is to get professional medical help. "While psychiatrists may be more familiar with medical treatments and the newest medications, primary-care physicians or ob-gyns are also good places to seek relief," notes Dr. Calabrese.

Getting the person to agree to seek help also can be difficult. "You might approach your loved one by saying, ‘I know you may not feel you need help, but I'd feel better if a professional had the opportunity to evaluate your situation objectively,'" suggests Dr. Saenger. And, she adds, it's helpful if a caregiver also accompanies the person to see the doctor, especially in the case of bipolar disorder, because "the person may not remember the manic-or ‘up'-swings, whereas family members might."

Before help can be given, a patient can expect to be interviewed and possibly have a physical examination to reveal any specific symptoms, medical and family history, cultural settings and environmental factors that would help determine the best treatment.

For depression, medication (usually a selective serotonin reuptake inhibitor or SSRI) and/or psychotherapy or cognitive therapy (sometimes called "talk therapy") may be prescribed; both treatments "attack" different parts of the brain. "Cognitive therapy has a good track record for depression but it must be tailored to the individual," notes Dr. Saenger. "This usually consists of eight to twelve weekly, structured working sessions, often with homework after each session." Some antidepressants start working within the first few weeks of treatment, but full benefits may not be felt for two to three months. During counseling, meds and dosages are reevaluated. Depending on the severity and number of depressive episodes, taking meds may be temporary or lifelong.

Because bipolar disorder tends to be recurrent, long-term preventive treatment is strongly recommended. Medication (usually referred to as a "mood stabilizer") alone or in combination with psychotherapy is optimal. Even when there are no breaks in treatment, mood changes still can occur, so it often is recommended that sufferers benefit from working with a psychiatrist. "There are written, evidence-based guidelines for the pharmacologic management of mania and depression, and different maintenance treatments following episodes of both phases," Dr. Saenger points out. And since bipolar disorder can cause serious disruptions and create an intensely stressful family situation, family members also may benefit from professional resources, particularly mental-health advocacy groups and support groups.

Living with Depression or Bipolar Disorder
As with other chronic illnesses, people with mood disorders should see themselves as managers of their illness. While neither condition is curable, both are treatable. By continuing a treatment plan, a patient can greatly reduce the odds of symptom recurrence.

One of the biggest problems faced by both patients and caregivers, says Dr. Calabrese, "is that adherence to treatment is difficult to maintain when you're feeling good." Also, society does not tend to diagnose and treat mood disorders as seriously as it does other chronic illnesses.

Regardless, it's important to be supportive and understanding, and to help the person stick to the treatment plan. "Caregivers need to negotiate with the person as an adult and stay attuned to see where he or she needs help, " Dr. Saenger notes. "Some people with mental illness resent interference, while others want some degree of collaboration. It depends on the person."