Expert Commentary

Bipolar Characteristics Seen In Treatment-Resistant Depression

Michael Robert Clark, MD, MPH, MBA, Joyce King, MD, and Glenn J. Treisman, MD, PhD

Michael Robert Clark, MD, MPH, MBA
Associate Professor & Director, Chronic Pain Treatment Program
Department of Psychiatry & Behavioral Sciences
The Johns Hopkins Hospital
Baltimore, MD


Joyce King, MD
Chair, Patient Care Advisory Committee
Director, Inpatient Training for Family Practice Residents
Franklin Square Hospital
Baltimore, MD


Glenn J. Treisman, MD, PhD
Professor of Psychiatry and Behavioral Sciences and of Medicine
Director, AIDS Psychiatry Service
The Johns Hopkins University School of Medicine
Baltimore, MD

Patients with treatment-resistant depression may show symptoms of what appears to be comorbid bipolar disorder. However, while some studies suggest a continuum between bipolar disorder and major depression, there is, as yet, no firm consensus. In patients with treatment-resistant depression with bipolar component the diagnosis may reflect a presentation of significant anxiety mixed with symptoms of other mood disorders. Since many treatment-resistant patients will redefine their baseline mood, accepting a mildly or moderately depressed state as normal, the assessment of any elevation in mood may be misinterpreted as hypomania.

Patients who present with refractory depression, often tend to be more agitated or anxious, and are, therefore, both more likely to be labeled bipolar and less likely to respond favorably to referral to a psychiatrist or adhere to a psychotherapy regimen. Because of this it is generally understood that initial treatment by their primary care physician (PCP) may be more effective than immediate referral to a psychiatrist. Further, once depression is stabilized, most PCPs are able to effectively manage their patient’s illness. The ideal approach is for the PCP to do this in active consultation with a psychiatrist.


The therapeutic goal for treatment-resistant depression is complete remission. Partial remission frequently leads to relapse and can exacerbate other medical problems, such as diabetes, asthma, or hypertension—all of which partially-remitted patients typically neglect. Because patients who routinely see their psychiatrists often do not see their PCPs, worsening comorbid medical conditions may be missed. Too often, psychiatrists will not contact their patient’s PCP when they observe these conditions, assuming that the problem is being addressed. It is therefore critical that a solid working relationship between the psychiatrist and PCP is established and maintained.


  1. Chilakamarri JK, Filkowski MM, Ghaemi SN. Misdiagnosis of bipolar disorder in children and adolescents: a comparison with ADHD and major depressive disorder. Ann Clin Psychiatry. 2011;23(1):25-9.
  2. Berk M, Berk L, Moss K, Dodd S, Malhi GS. Diagnosing bipolar disorder: how can we do it better? Med J Aust. 2006;184(9):459-62.
  3. Kates N, McPherson-Doe C, George L. Integrating mental health services within primary care settings: the Hamilton Family Health Team. J Ambul Care Manage. 2011;34(2):174-82.
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