Bipolar Disorder: Understanding Predominant Polarity and Its Impact on Diagnosis and Treatment

This podcast episode by Dr. Tracey Marks delves into the concept of "predominant polarity" in bipolar disorder, explaining that about half of individuals with the condition spend significantly more time in either a depressive or manic/hypomanic phase. The episode distinguishes between Bipolar I and Bipolar II, as well as mixed and rapid cycling types, setting the stage for understanding how predominant polarity (defined as having at least twice as many episodes of one pole over the other) profoundly influences the course of the illness and its treatment. This nuanced perspective highlights that bipolar disorder is not a uniform experience of alternating episodes, but rather a spectrum with distinct patterns of presentation and progression.

The episode elaborates on Depression Polarity Predominant (DPP) individuals, who often experience their first episode as major depression and may be misdiagnosed as having unipolar depression. This misdiagnosis frequently leads to treatment with antidepressants alone, which can paradoxically worsen bipolar disorder by triggering rapid cycling or creating agitated mixed episodes. Dr. Marks emphasizes that while some individuals might tolerate small doses of antidepressants with a mood stabilizer, the standard recommendation is mood stabilizers first. A critical challenge for DPP individuals is the less effective antidepressant options for bipolar depression compared to antimanic treatments, leading to more time spent unwell. Furthermore, forgetting past hypomanic or manic episodes can lead to doctors discontinuing crucial mood stabilizers, resulting in a relapse into depression or a mixed state.

Conversely, the episode examines Mania Polarity Predominant (MPP) individuals, who typically present with mania at a younger age and often exhibit psychotic symptoms like grandiose or religious delusions during manic phases, or persecutory delusions during depressive states. While manic episodes can be highly destructive due to unpredictable behavior and poor decision-making, Dr. Marks notes that mania is generally easier to treat than bipolar depression. This is attributed to the superior efficacy of antipsychotics and mood stabilizers in slowing down mania compared to lifting depression. For MPP individuals, staying in contact with their doctor and having social support can lead to better treatment outcomes by catching symptoms before they spiral out of control.

Dr. Marks discusses the implications of predominant polarity for medication choice, mentioning ongoing research into a "polarity index" to guide treatment. She lists FDA-approved medications for bipolar depression, including Quetiapine (Seroquel), Vraylar, Latuda, and CAPLYTA, and notes Lamotrigine's common off-label use. A key warning is issued for MPP individuals against using antidepressants for depression, as they are more prone to flipping into mania or mixed episodes; alternative strategies like adding another mood stabilizer, lithium, or light therapy are suggested. For those with a new diagnosis, Dr. Marks strongly recommends keeping a mood journal to track episodes, duration, and polarity, providing invaluable information for doctors to optimize treatment and ensure a smoother transition between healthcare providers.

About half of the people with bipolar one or two, spend a predominant amount of time at one pole over the other.

This is called predominant polarity and it's defined as having at least twice as many episodes of one pole over the other.

Antidepressants tend to make bipolar disorder worse by triggering rapid cycling or creating mixed episodes, where you have this awful agitated depression.

But admittedly, our antidepressant treatment options are not as good as the antimanic options, and this is why people with the depression predominance tend to spend more time not feeling well.

Even though mania tends to be more destructive, creating a devastating path of bad decisions and negative consequences, from a treatment standpoint, mania is much easier to treat than depression.

Because the antipsychotics we use as mood stabilizers are much better at slowing down mania than they are at lifting someone out of a depression.

If you are mostly manic with infrequent depressive episodes, an antidepressant is more likely to flip you into mania, a mixed episode, or send you rapid cycling.

If your bipolar disorder is a new diagnosis and you don't have enough of a pattern to establish a predominance, it's time to keep a mood journal.