Depressive disorder is among the most common mental health disorders affecting people in the U.S. and Canada: 12-month prevalence of any depression in the U.S. is 9.1%, and 7%% for major depressive disorder.5,6 The condition is more common in persons with other chronic medical illness such as diabetes, heart disease and obesity. The female-to-male ratio for the diagnosis is approximately 1.5-3:1. The spectrum of symptom severity is wide, and most people with depressive disorder work. Nevertheless, depressive disorder is a major cause of disability in the general population. A 2010 study suggests it is the second largest cause of disability worldwide.7
For purposes of this document, we will consider both the DSM-5 diagnoses of major depressive disorder and persistent depressive disorder (PDD.) The latter diagnosis is an amalgamation of dysthymia and chronic major depressive disorder, two DSM-IV TR diagnoses.3 PPD has a wider spectrum of clinical severity than its two components. A comparison of diagnostic criteria from DSM-IV TR and DSM-5 is provided in Appendix A as not all mental health providers have adopted DSM-5 at the time this guidance was developed.
Symptoms of depressive disorder lead to marked distress, and impairments of cognition, judgment, and, interpersonal relationships. Sleep and appetite disturbances are common, as is psychomotor retardation, and impaired concentration which may decrease cognition and reaction time. Over 50% of persons experiencing a major depressive episode (MDE) acknowledge feeling it would be better if they were dead and 30-40% consider suicide.8,9 Suicidality is of special concern in LEOs given their ready access to firearms. Approximately 15% of individuals with major depressive disorder kill themselves, with availability of a firearm as a major risk factor; owners of firearms have a 3-12 times higher risk of a lethal suicide attempt.
Of those experiencing moderate to severe major depressive disorder, 50% will improve with treatment.10 Successful treatment often occurs within 1-3 months.11 However, 12-35% of depressed patients do develop a chronic form of the disorder. Risk of recurrence is also high, 50% after a single episode, 75% after two episodes, and 90% after a third. This underscores the importance of ongoing evaluation after return to work following treatment for this diagnosis.
Treatment modalities include antidepressant medications, adjunctive treatment with other classes of psychoactive medication (e.g., aripiprazole, lithium), electroconvulsive therapy (ECT), transcranial magnetic stimulation (TMS) and psychotherapy (particularly cognitive-behavioral psychotherapy and interpersonal psychotherapy). ECT bears specific mention as this therapy involves electric stimulation of the brain which produces seizure-like activity. Post-treatment impairments of cognition and memory are usually transient but may persist for months.
“Bipolar disorders are separated from the depressive disorders in DSM 5 and placed between the chapters on schizophrenia and other psychotic disorders and depressive disorders in recognition of their place as a bridge between the two diagnostic classes in terms of symptomatology, family history and genetics.”3 DSM 5 recognizes several bipolar and related disorders:
- Bipolar I
- Bipolar II
- Cyclothymic Disorder
- Substance/Medication-Induced Bipolar and Related Disorder
- Bipolar and Related Disorder Due to Another Medical Condition
- Other Specified Bipolar and Related Disorder
- Unspecified Bipolar and Related Disorder.
Diagnoses in this class are associated with severe disturbances of mood, including mood instability, markedly elevated risk of suicide, and impaired judgment. Up to two-thirds of bipolar patients will experience psychotic episodes.12 Occupational and social consequences are often severe. The risk of recurrent impairing episodes is as high as 90%. Possible exceptions are substance/medication-induced bipolar and related disorder, and bipolar and related disorder due to another medical condition – in cases where exposure to a specific precipitant can be completely controlled.
Taken together, the three most common bipolar diagnoses, bipolar I, bipolar II, and cyclothymic disorder affect 1.5-2.0% of the population. Diagnostic criteria for all of these conditions require that “the symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.”3 All are recurrent by definition, and associated with impairment of cognitive processes, judgment and impulse control which create important concerns for the police physician.
To meet the diagnostic criteria for bipolar I, the LEO must have experienced at least one manic episode. Some LEO’s may experience only manic episodes, some a combination of manic as well as major depressive episodes (MDE), and some only MDE as long as they met diagnostic criteria for a manic episode at some point in their history. Of note, a manic episode may have preceded or be followed by a major depressive episode or a hypomanic episode. Episodes may last from days to months – and there may be no intervening period of normal mood. Changes in mood are unpredictable and can be abrupt. When more than four distinct episodes occur in 1 year, the designation of “with rapid cycling” is used. Rapid cycling is associated with greater risk of suicide and poorer prognosis in general.
Mania is characterized by expansive, usually elevated mood (euphoria) or may present with only an irritable mood. In addition to this mood disturbance, individuals may exhibit grandiosity, inflated self-esteem, less or no need for sleep, distractibility, increase in speech and motor activity, and impulsivity. Unfortunately, thinking may become illogical and disordered. The manic individual typically lacks insight into the impairment of their thought process. This may lead to gross overestimation of their own abilities, impulsive and outlandish behavior, and failure to observe social conventions. Family problems, legal complications, financial, and sexual indiscretions are common. Psychosis occurs in a high percentage of bipolar I cases. Patients may experience delusions of grandeur (e.g., thinking they are Jesus Christ or the President). Impaired judgment leads to elevated risk of accidental death during manic episodes.
In contrast, depressive episodes leave the patient with severely depressed mood, anhedonia, hopelessness, feelings of guilt and worthlessness. Changes in sleep (insomnia or hypersomnia), changes in appetite (anorexia or hyperphagia) and reduced energy are typical. Psychotic features, such as auditory hallucinations or delusions may occur. The major depressive episode as defined for major depressive disorder has the exact same diagnostic criteria as that of bipolar I or II; the only distinction is that to meet criteria for bipolar I, the individual must have had a manic episode, for bipolar II, a hypomanic episode. As is true of all major depressive episodes, impairment cognition and reaction time may occur.
In bipolar II disorder, the LEO must experience one or more episodes of major depressive disorder lasting at least 2 weeks and one or more episodes of hypomania, lasting at least 4 days. The presence of a manic disorder at any time during the illness changes the diagnosis from bipolar II to bipolar I. This occurs in 5-15% of bipolar II patients.
A hypomanic episode is a distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy, lasting at least four consecutive days and present most of the day, nearly every day. By definition, the episode is not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization. During periods of hypomania, patients may feel unusually productive and creative.
As is true of bipolar I disorder, diagnosis of bipolar II in childhood or adolescence is associated with a more severe lifetime course. Rapid cycling is associated with worse prognosis: 15% of patients have inter-episode dysfunction and 20% go from one episode to another with no inter-episode recovery. When periods of recovery occur, restoration of cognitive function lags resolution of symptoms significantly. This affects vocational performance negatively.
Typical age of onset is mid-20s, starting with a depressive episode. At the time DSM-V was published, 12% of persons initially diagnosed with a depressive disorder were subsequently diagnosed with bipolar II after a hypomanic episode. Angst, in a 2013 study, suggested that changes in classification of hypomania in DSM-IV TR and DSM-V will lead to a marked increase in diagnosis of bipolar II in those previously diagnosed with major depressive disorder. In DSM-V, hypomania arising in treatment of major depressive disorder is an explicit criterion for bipolar II. In DSM-IV TR it had been an exclusion criterion for bipolar II.13 For the police physician, knowledge of this change in diagnostic categories is important in communicating with the treating providers of LEOs with depressive disorder, bipolar II, and substance/medication-induced bipolar and related disorder.
Cyclothymic disorder is a chronic mood disturbance involving numerous distinct periods of hypomanic symptoms and depressive symptoms which do not by definition meet criteria for hypomanic or major depressive episodes in terms of number, severity, pervasiveness, or duration. There is a 15-50% lifetime risk that a cyclothymic patient will experience mania, a hypomanic episode, or a MDE at which point the diagnosis of bipolar I or II is made.
Substance/Medication-Induced Bipolar and Related Disorder
LEOs in this diagnostic category experience mood changes similar to those with other bipolar disorders, but symptoms can be shown do develop during or soon after substance intoxication or withdrawal, or after exposure to a medication. Additionally, the implicated substance or medication is known to be capable of inducing these symptoms. Causal agents include amphetamines, cocaine, steroids, sedatives, hypnotics, anxiolytics, and others.
Bipolar and Related Disorder Due to Another Medical Condition
LEOs in this diagnostic category experience mood changes similar to those with other bipolar disorders, but there is evidence from history, physical examination, or laboratory testing that the disturbance is the direct pathophysiological consequence from another medical condition.
Complications and Comorbidities of Bipolar Disorders:
Suicide risk is markedly elevated in persons with bipolar disorders – some 15x population baseline. Despite the relatively low prevalence of bipolar disorders, bipolar patients account for up to 25% of all suicide attempts and 20% of suicide deaths.
Bipolar patients are also highly likely to experience other mental health disorders – 75% will experience some form of anxiety disorder, and 50% will experience some disorder of impulse control or conduct, e.g., ADHD, intermittent explosive disorder, or conduct disorder.
LEOs with bipolar disorders have a very high risk of concurrent substance abuse, greater than 50% in cases with bipolar I. Concurrent substance abuse can interfere with treatment of bipolar disorders.14 Those dually diagnosed with bipolar disorder and substance use disorders are at higher risk of suicide.
Non-adherence: A recent British study found that >50% of bipolar and schizophrenic patients interviewed took their medication in ways their physicians had not intended; 29% were satisfied doing so.15 Manic and hypomanic patients often experience a sense of well-being and do not acknowledge the need for treatment.
Treatment of Bipolar Disorders
Medication is the primary treatment for bipolar disorders. Psychotherapy, such as cognitive behavioral therapy (CBT) can be a useful adjunct. In some cases, electroconvulsive therapy is used to assist in mood stabilization.
Lithium or anticonvulsants such as valproate, lamotrigine or carbamazepine are usually first line for mood stabilization. Antipsychotics may be used to control mania; usually in addition to a mood stabilizer. There remains considerable debate regarding the use of antidepressant medications for the treatment of depression in bipolar disorders.
Lithium, the most commonly used agent, has a narrow therapeutic range and therapeutic drug monitoring is required. Toxicity can result in cognitive impairment and altered gait.
Medical treatment results in reduction of mood episodes by 30-40%. Episodes continue to occur in most treated patients.16 Of the medications used, only lithium has been shown to reduce suicide rates among bipolar patients. This effect is substantial, an 80% reduction of lifetime risk.17 As noted above, non-adherence is a particular problem in bipolar disorders.