It does not matter for the 150 but for current or future depressed, it matters a lot because the treatments and outcomes differ substantially between the two types of severe depression, Unipolar and Bipolar. Bipolar is defined by one or more lifetime manic or hypo-manic episodes. Unipolar depression can change to Bipolar with an occurrence of mania; there is no reversal from Bipolar to Unipolar.
The treatment of choice for Unipolar depression can make Bipolar depression worse so the correct diagnosis is critical but difficult because the depressive symptoms can be identical in Bipolar and Unipolar depressed patients.
Two world authorities on Bipolar disorders are Drs. Fred Goodwin and Kay Redfield Jamison.(1) There are other contributions to the differential diagnosis of severe Bipolar.(2)
Additional ways of trying to identify likely bipolarity in depressed patients exist. Some of these are relevant to Mr. Andreas Lubitz, 27, the co-pilot of 9525 who likely set the record for the number of victims killed although there are many other examples of psychotic mass murderer-suicides.(3) The 911 killers were not psychotic.
Media efforts allow mental health workers an ability to develop a reasonable profile of such perpetrators of mass murderer-suicides. According to the media, Mr. Lubitz had been prescribed "antipsychotic" medications suggesting that he suffered a psychotic episode. Frequent and severe depressive episodes, even if not psychotic, typically are part of a Bipolar disorder. The age of onset of a Bipolar disorder, which usually begins with depression, is in the late teens to early 20's, substantially younger than for Unipolar. Mr. Lubitz had had at least one prior severe episode during flight school at age 21 and "had been treated for a long period of time."
A past history of accomplishments, successes and any hint of grandiosity also suggests that an episode of severe depression is part of a Bipolar disorder Mr. Lubitz graduated from the Lufthansa flight school. He was described as a "cheerful and careful pilot" and was an accomplished distance runner. That he chose to take out 149 innocent souls as well as a $70-million Airbus A320 hints if not screams grandiosity because jumping, cutting, shooting, hanging, or overdose, are far more mundane yet effective. Further evidence that Mr. Lubitz's depression was Bipolar was found in his computer searches. According to media reports, in addition to cockpit doors, he also searched manic-depression and Bipolar. Future media revelations of a past or family history of mania or use of lithium would be convincing.
The treatment for Unipolar depression is antidepressant medications but these may be contraindicated alone in the treatment of Bipolar depression because they can cause a direct switch to mania and/or increase the rate of cycling. Antidepressant medications were found in Mr. Lubitz's residence. The treatment of choice for Bipolar depression is one or more mood stabilizing medications, lithium, valproate, carbamazepine, lamotrigine, with or without an antidepressant. I saw no mention of any of these being found.
The right treatment saves lives; the right treatment requires the right diagnosis.
1. Manic-Depressive Illness; Oxford University Press, 2007.
2. Schizophrenia is a Misdiagnosis; Springer, 2012.Psychotic Rampage Killers; Psychiatric Annals, Vol 44, May 2014.
C RAY LAKE, MD, PhD
Professor Emeritus, Department of Psychiatry and Behavioral Sciences