Category Archives: #Bipolar Mood Disorder (Bipolar Depression)

Hansie’s story

To give you some insight into my life, I’ve decided to share ‘snapshots’ of my life with you … those milestone events that essentially make Hans Dreyer, Hans Dreyer. It’s never easy to look back and communicate these things with raw honesty; to peel back those protective layers that hide the pain … but it’s so important. Through this series I hope you’ll somehow be able to better relate to the man behind the advice … to understand that I’ve ‘been there’ and ‘done that’. Above all I hope that my struggles (and my victories) will encourage you to see that Bipolar Disorder can be a blessing if you understand it, and that you can learn how to live a successful, enriching life despite it. You CAN achieve amazing things, and it’s NEVER TOO LATE to embrace this truth! Bipolar Disorder needn’t be the terrible monster that ruins families, promising careers and lives.

Let me start by sharing the single most tragic event in my life … the death of our youngest son, Hansie.


Then you did it… that one thing that we were so afraid you’d do. It was one wintry Wednesday; a day that started like any other day… Paulina still made you tea when you came home from school that day; you weren’t feeling well, you told her. Then she heard you locking our bedroom door. She even heard the safe key ‘click’ as it unlocked. While she stood around, wondering what on earth she should do next, Paulina heard the shot that shattered our hearts into thousands of little pieces.

Panic-stricken, she ran into the street… it was exactly the time that moms picked up their Grade 1 and 2 kids from the Primary School across the road from our house. She ran up to the first mother she saw, hysterically clinging to her and begging her to come and help. They rushed into our house together. By this stage, blood had already begun to seep through the floorboards of the top story.

The telephone call I received, somewhat prepared your mom and I for what was to come. “You need to come home right away. There was a shooting accident. The bedroom door is locked, and there’s blood.”

On the way home, Mom and I prayed that it wouldn’t be serious… that you’d only managed to fire a shot through your arm or shoulder… that you’d still be with us. I dashed up the wooden staircase and kicked our bedroom door down. Mom stayed in the kitchen… her eyes transfixed on the blood seeping through. There was no way someone would still be alive after losing all that blood…

There you lay on the floor, with your pillow and duvet… on the spot that you and Mom still huddled together in front of the heater that morning… did you feel safe here? It was horrific… your face, blue… and the bullet wound in your head. The entry wound was on the right hand side, and Mom felt sick when she remembered a conversation she’d had with you a few weeks earlier. You had asked her professional opinion as a GP, whether it was true that the temporal bone was the thinnest part of the skull, and she’d confirmed that. The exit wound on the left hand side was where damage was clearly evident… where the blood had gushed out.

Mom ran upstairs, fell to her knees and held you… the paramedic said, “You can leave him, Ma’am, he’s already brain-dead.” But when she took your hand in hers, she could clearly feel a pulse… her hands instinctively moved to feel a pulse in the jugular vein… there was a strong pulse there! Our precious, gorgeous 14 year-old curly-haired, blue-eyed boy… Her anxious cry shook the indecisiveness right out of the paramedic. “My child’s heart is still beating… DO SOMETHING!!”

“Oxygen saturation of 60%,” he announced after pegging the meter to your thumb. “Sixty percent is not good enough… bring a respirator, quickly!”

The policeman at the scene had one objective: to get Mom away from you and out of the room, at all costs. I calmly held her and said, “My wife’s a doctor. You’re not going to get her out of the room like this.”

My calmness seemed to help calm Mom down somewhat, and it dawned on her that she was just trying to postpone the inevitable. She knew from that first moment that your brain would have been so damaged, that it would never be able to be reconciled with what we know as ‘life’… it would have been foolish to keep your body alive without any chance of your brain being able to function on its own… and yet, we still decided to have you taken by ambulance to H.F. Verwoerd Hospital (now known as Steve Biko Hospital). Meanwhile, news spread to our nearest and dearest… if I recall, it was your big sister Hanri who had the composure to make that first call.

Funny the things one remembers… I remember grasping at sips of tea through the tears… my mouth felt like cork. Where did everyone come from? They made more tea, they held us, they prayed with us and made more telephone calls… Was it half an hour? Maybe an hour… it felt like time stood still at that stage… we decided to leave to go to the hospital. Your best friends Henno and Christo accompanied us, as did Henriëtte, the girl who stole your heart. Eventually three cars were packed with the friends who used to come home with you after school, and a few of Mom’s and my close friends.

On the way, Mom and I read each other’s minds and hearts… we decided, almost with one breath, that your organs should be donated. It’s funny how, prior to that moment, the very notion of organ donation made me feel claustrophobic… when Hanri had still wanted to purchase a ‘Medic Alert’ bracelet in order to record her organ donor status… it was as if the idea had ripened in our subconscious minds.

A pleasant, upbeat young doctor met us in the Trauma Ward and took us to you. “But Auntie Mariëtte, he’s still breathing – look how his chest is still moving rhythmically!” Henriëtte got this short-lived flash of hope in her eyes. “No my love, it’s the machine that’s doing his breathing for him… he can’t do it on his own anymore,” Mom explained.

We stood there with our hands on your chest … tears crashing down mercilessly … your hand was still warm to the touch, just like that of any patient who was being kept alive against the odds. I think you were already in heaven, my boy… it was your body lying there… the bullet wound didn’t look so horrific any more… it was covered with some gauze and plaster… looked so ordinary.

We surrounded your bed and I prayed… not that you’d carry on living, but that the Lord would give us strength and serenity.

After all of us said our goodbyes, the Head of the Organ Donor Team was standing to the side, waiting to brace the topic. Fortunately, we were prepared for this… the signatures were a mere formality.

At 11 o’clock that night, you were officially declared dead, with the cause of death recorded as ‘heart failure whilst under unaesthetic’. Despite it being a time of intense pain and mourning, we were warmly wrapped in the comfort of those who cared about us.

Your pals lay around on our lawn and spoke, just like they used to, most days after school… except they were gutted … the wind had been knocked right out of them… especially young Dewan… another member of your inner circle, who only found out about the tragedy at Rugby practice that afternoon.

I had always wondered what it would be like to stand at the deathbed of a child… would I cry hysterically? Would I remain in control and try and ‘fix’ the situation? When you and your siblings were small, mom still had such a fear of something happening to one of you. We were a wonderful family… Hanri aged 23, Tom aged 22, 16-year-old Tiaan, and you, my special one, you who were only 14. You had an incredible connection with each other… so much so that people actually remarked on the unique bond.

Back in the early days I prayed and asked God please to protect you children… and even though I ended my prayer with, “Lord, your will be done”, I still had this underlying angst… I used to wonder what if God were to call one of you home early. Until one day. Up to this point I felt as if I was wrestling with God about this… and on that particular day, it was as if the Lord said to me, “My child, if it must happen, I’ll give you the strength and the grace you need, to deal with it.” That peace thankfully stayed with me for years… the realisation that I couldn’t look after each of you, 24/7, eventually set me free. I realised that only God could be with you all, round the clock.

The day after the tragedy, our friend Judith came to us with a scripture… Genesis 15:6: “… and he believed the Lord, and He credited it to him as righteousness…”
This was a huge comfort to me. Although I knew beyond a shudder of a doubt that you had accepted Jesus as your saviour, I asked God if He would please send someone along our path, with a verse, just for us.

Then another friend came with this verse from Job 14:5: “Man’s days are determined; You have decreed the number of his months and have set limits he cannot exceed…”

This was the beginning of a new perspective on your death. God established the days of your life as well. When Mom was pregnant with you, it was almost as if God didn’t want any of her planning in the scheme of things. While her other two pregnancies involved fertility treatment, it hadn’t been so with your conception. Even though we wanted a family with four children, God did it HIS way when it came to you. You were the only little one that Mom was able to breastfeed, and she kept thinking, “Hansie, I’m raising you for myself.” Mom always went on about the other three kids being nuts about me, and that she’d dearly wanted a child who was just crazy about her! (I protested profusely, but we all know how moms can be sensitive about this sort of thing, right?!)

According to mom, this was not to be! You were the one who crept even deeper in my heart, my special boy. Always ready for a hug or a kiss, right up to just before that fateful day. You were the sensitive one, especially when it came to Mom’s and my feelings. You never wanted us to be sad or worried about anything. Is this why you hid your Depression so well? So that we wouldn’t worry more?

I remember when you were in Grade 7 (Standard 5 in those days). You were so depressed and filled with anxiety that winter… you just wanted to hide away… Mom recalls you burying your head under her arm if you’d go to the mall. When spring arrived, you seemed to feel better. Then, in Grade 8, (Standard 6) there was the time that you fired a shot into the ceiling… the barrel of the pistol still seared your cheek…

After three weeks of treatment in the adolescent unit of a psychiatric clinic, everything seemed to go better. Yet now, in retrospect, we sadly recall little things you said, which we didn’t realise at the time were pointing to the fact that that black helplessness called Depression was encroaching on you yet again. You most certainly planned the end, even though there was no note. The safe key was returned to its place; the furniture was repositioned in front of the safe… almost as if you were trying to tell us that this wasn’t an impulsive decision, an accident… it was a deliberate act that you definitely didn’t want to have anyone intercept… and so you locked our bedroom door just to make sure…

Suddenly, so many puzzle pieces fell into place, in respect of the patients we’d counselled for Depression. I suppose I’ve become resigned to the fact that some people, who are in such a dark place where their mood and emotional state are so disturbed, experience a complete annihilation of their survival instinct. In its place, an urge to self-destruct takes over. If one suicide attempt isn’t successful, they try until they get it right.

This is why we know that suicide isn’t that ‘unforgivable sin’… that moment when your death precedes your logistical ability to ask for pardon… Suicide is the most serious symptom of a seriously sick individual. It’s the final symptom in the build-up of a disease… as impossible to prevent in some people as it is to prevent the rupture of an artery, resulting in a stroke, in other people with hypertension.

Mom’s sister-in-law Christine coined it in her note of sympathy after that terrible night: “At the end of the day, Hansie… holding his big-man cigarette, with his taut rugby physique, was just a scared, sick little boy who was standing up against this broken world, and the outrageous demands it makes on our children.”

How low you must have felt… at least, now, you are finally free from that prison of despair, my boy. You’re sitting with your Father in Heaven, never again to be assessed by worldly standards that only caused you pain and disillusionment. How comforting to know that you passed the most important exam on earth, with flying colours… the test of true love. Even your youngest cousin could recall your expressions of affection, and your patience with the little ones!

Never again will anyone complain about your ‘illegible handwriting’ or your hair that’s half a centimetre longer than it should be, according to those school rules!

Cousin Thomas clearly remembered your conversation with him, just a few days before your death, about organ donation. Thomas said there was NO way he’d be an organ donor… that it paints the most horrific mental pictures for him… and yet you returned to this topic several times that day, stressing that ‘It would be cool to donate one’s organs to someone who needs them!’ Do you know how relieved we were when Thomas told us this?

When we heard that you had been declared dead during the anesthesia, we were wondering whether you had died before your organs could be harvested successfully, as you had wished… but later on, a friend told us that a man in her home meeting group had been pushed into theatre at 10 p.m. that very night, with kidney failure. He had undergone dialysis three times a week, and that night, your kidney saved his life, my boy! Your other kidney was donated to a man who had been waiting for a suitable donor, for 16 years.

I believe that, since the time you were born, God planned that you’d be the ‘match’ that would save those two people’s lives. The corneas in those gorgeous blue eyes of yours were donated to a woman who was so short-sighted, she was due to receive a guide dog the following week… thanks to you, she can see today! Even your strong, fit, healthy heart is beating in someone else’s ribcage today.

These realisations left us comforted… even excited, knowing that your death wasn’t in vain… your story made such an impact on certain people that it was the beginning of a whole new adventure with their Heavenly Father for them.

Rest in Peace, my boy… and know that I am at peace, because you are finally at peace, enjoying the sheer glory or heaven alongside your dear Mom who passed away unexpectedly, many years after you. Love you forever, Hansie.

On getting rid of negative thoughts …

A depressed young man sat down next to the grey-haired, stooped figure of his elderly grandfather.

Why are you looking so sad and sorrowful?” the old man asked.

Grandpa, I feel like I can’t find any rest, day or night. I feel utterly useless; that I’m a disappointment to all the people I once loved. I feel like I’ve messed up my whole life. When I’m around other people, I make them feel sad. I doubt if there’s anyone out there that still loves me,” the young man explained. It’s as if my conscience is constantly accusing me of being useless and disappointing my parents and friends.”

The grandpa sat quite still for some time, pondering over his grandson’s dilemma, stroking his grey beard and deeply in thought.

You must learn to correctly identify the voices talking to you and accusing you” the old man gently whispered.

Let me tell you an age-old tale; a story that was carried on from one decade to the next one, as a story told by the wise old men from the tribe, to the children when the nights are cold and they huddle together around a small cooking fire,” he continued …

There was an old man who felt sad and useless; the love of his life could not give him a son for future generations. She remained barren despite the two of them trying everything they knew of, to conceive. They also fervently prayed for a miracle.

In total despair his wife told him, “Please take my slave girl for yourself; take her to bed and let her conceive your child. Her child will be my child, as our ancient customs dictate, under such circumstances.

The slave girl fell pregnant and gave birth to a son. But the she didn’t react subserviently as the custom dictates. She believed she was superior to her barren mistress, and mocked her. The mistress was deeply hurt, and got very angry. She banished the haughty slave girl, sending her into the desert. An Angel appeared to her and urged her to go back and to submit.

Years later the mistress fell pregnant as well; this was nothing short of a miracle. When her young son reached the age of about four, the family had a weaning festival as tradition required.

There were already hard feelings between the banished slave girl who had borne the husband’s first child, and her mistress; and this negative feeling spilled over into the older son’s attitude. He started mocking his younger (half) brother incessantly, and never let up.

Eventually the younger son was ready to explode with frustration. He ran to his mom and said, “My older brother keeps on belittling me in front of all the visitors, he keeps on mocking me, please help me,” he cried. “I can’t take it anymore!”

The old man’s love of his youth ran to him pleading, “Please tell your older son and his mother to leave us! Their attitudes are absolutely uncalled for! They’re turning our son’s life into a misery!”

The old man looked at her with astonishment. “You know I can’t do that! She is my wife by law! You told her I should take her and conceive a child with her! Her son is my own son … in fact, according to tradition he is your son, and I can’t send them away into the desert!”

This explanation did nothing to placate his real wife. She kept nagging and nagging as only a woman could do. “Send them away! Send them away! Tell them to go!”

When he couldn’t stand it any longer, in total despair he relented. “Alright then! If you keep on, and on, and on, pressurising me to send them away, why don’t we go and pray and ask God what we should do. Then you will hear God telling us that I can’t send them away; they are my family according to our tradition, and I have a legal responsibility towards them.”

So they went to a quiet place to seek God’s presence and to pray.


It can’t be true, we must be mistaken, listen what God is saying” the old man cried. “God said, ‘Send them away, the son of this slave girl may not inherit anything from all your riches! There is not enough for both of them; only your real wife’s son may inherit.’ “

But Grandpa, what are you trying to tell me through this age old story?” the depressed grandson was confused. What is the connection between this story and my terrible fight with my conscience accusing me?”


The slave girl and her son represent laws made by men to live by. According to the teachers of that era 2000 years ago, living by certain rules was the only way to attain inner peace and peace with God,” the grandpa goes on to explain.

But these man-made rules are harsh and almost impossible to adhere to. Consequently, it is almost impossible to achieve that sought-after peace of mind, and peace with God.”

The younger son, borne years later by the old man’s first love, symbolises something totally different,” he continues. “The last-born son stands for the fact that we can resist the accusations brought on us by man-made traditions (the older son, whom the slave girl gave birth to). We have the assurance that God allows us … wait, no; he actually orders us, to send that ‘older son’ and his accusations packing! He gives us freedom. He sets us free from all the mockery of the ‘older son’.”

The grandpa turns to his grandson. “You see, this ‘son’ and his mockery of you, is pretending to be your conscience. He wants you to believe that it is your conscience that accuses you of not being good enough; of being a failure. Of being someone you should be ashamed of being. But this is not true. This ancient fable reveals what God wants you to do when you’re faced with all these inner accusations and self-doubt: ‘SEND THEM AWAY! BANISH THEM!’ It’s not your conscience condemning you. It’s man-made rules and traditions that condemn you and bring you down!”

The younger son of the old man’s first love, represents the freedom that God gives us. There is not enough energy in you to listen to both these voices, they will totally and utterly exhaust you. Distinguish which one is the voice of the evil one. The one who pretends to be your conscience. Chase him away tell him to keep quiet! Tell him that God gave you a new direction… to not listen to that voice, to banish him! Turn around. Listen to the other voice, telling you that the accusations are false … telling you that you are free, that you have endless value in God’s eyes, and that is all that really matters.”

Ponder on this, my boy. It’s not your conscience accusing you, it is the evil who pretends to be your conscience. Send him away with the authority that God gives you. Instead listen to the other voice telling you how precious you are to God, and how much he values you, and that is all that matters. There is nothing of any higher value than God’s evaluation of you. Believe that. Keep telling yourself that, and you will be free!”

The young man rose from his grandpa’s porch chair, and straightened up for the first time in a long time. For the first time in many months, he had hope in his eyes. Against all odds, he decided to listen to the wise old man. To shut out the negative accusations. To embrace the freedom that was his; and by God’s grace, to live life seeing God’s worth of him.


Author’s note: This article was inspired by Dr Caroline Leaf, author of ‘The Perfect You’. In her book, she explains that the thinking of toxic thoughts can change gene expression in just the same way that exposure to chemicals and pollution does. Our DNA is developed to react to the language of our thoughts and the words following these thoughts. Recent neuro-scientific studies have shown that oxytocin, secreted by the brain, can literally ‘melt away’ negative thought bundles, thereby facilitating the ‘re-wiring’ of new non-toxic pathways. Dopamine works with the oxytocin to achieve this melting down of the negative thought bundles. We know that endorphin release makes us feel good, and also helps to ‘detox’ the brain. When we do good things, and when we reach out to others in love, endorphins are released, making us feel better. Broadly speaking, these findings collectively communicate the fact that our mind influences our brain. I encourage you to read this profound author’s work.


Author: Caroline Leaf

Year published: 2017

Book title: The perfect you

Publisher: Grand Rapids Division of Baker Publishing Company

Crisis in treatment of Depression and Bipolar disorder

The increasing rate of Depression in patients is becoming a huge crisis in South Africa and World wide

More than 17 million people in South Africa are dealing with depression, substance abuse, anxiety, bipolar disorder and schizophrenia-illnesses that round out the top five mental health diagnoses, according to the Mental Health Federation of South Africa. Furthermore,

A recent study showed that Depression cost the South African economy more than R232 milliard a year due to lost of productivity. Loss of productivity is caused by absence from work or attending work while unwell. That is 5,7% of the total South African annual economy.

London School of Economic and Political Science. (E-news 10/10/2017 at 19h00)

The incidence of patients with depression is increasing at an alarming rate as the following paragraphs clearly show.

The suicide rate for children aged 10-14 years old has more than doubled over the last fifteen years (3)

According to SADAG (South African Depression and Anxiety Group)

23 people commit suicide every day countrywide and a further 230 attempt to.

That is more suicides than America and the UK. (3)

The country have approximately 8 000 suicides a year. Around one million suicides were recorded each year globally.(3)

According to the WHO (World Health Organization) suicide is the 2nd leading cause of death among 15-29 year olds, with 1 person committing suicide every 40 seconds. For every person that dies by suicide, between 10-20 people attempt it.(3)

  • 1 in 4 SA teens have attempted suicide.

  • 1 in 3 hospital admissions for suicide involve youth.

“Depression and bipolar disorders form part of the top 15 diagnosis codes used, and contribute to some of the highest psychiatric benefits used during the 2013 service period,” (4)

Profmed’s member profiles in 2013, compared with last year, showed a 50% increase in those diagnosed with severe depressive episodes without psychotic symptoms.

There was also a 75% increase in Profmed members suffering from a severe depressive episode with psychotic symptoms for the same period.(4)


Bad “Patient compliance” and the alarming effects

75% of people will not get the mental health treatment they need.

Others continue on ineffective doses and medications due to clinical inertia and a lack of appropriate treatment intensification, in patients who are not improving with initial treatments. As a result, as few as 20 – 40 % of patients started on depression treatment in primary care show substantial clinical improvements. (2)

This high percentage of patients not showing substantial clinical improvement, indicates that about 60% of patients do not reach “remission” or “recovery.”

This may be one of the reasons why many people suffering from depression will not go to a clinician for help, because the population out there view treatment for depression as ineffective and a waste of money, since so many of their family and friends have been taking medication for years without any significant improvement.

Therefore adherence cannot be expected per se but needs special efforts on behalf of prescribers and public health initiatives.(1)

This article is based on the result of the research and planing of:

Dr Hans (JGM) Dreyer, Pastoral Counselor in Private practice in Pretoria.

Research Litterature available on request.


Contrary to common belief that the hormonal changes associated with pregnancy provide a protective effect against depression, women with major depression who discontinue antidepressant medication during pregnancy are at risk of relapse.

In a study published in the February 1 issue of JAMA, Lee Cohen of the Massachusetts General Hospital and Harvard Medical School conducted a study to determine the risk of relapse in pregnant women with major depression who discontinue or attempted to discontinue antidepressant medication close to conception compared with those who maintained treatment with these medications.

The study included a total of 201 pregnant women who enrolled between March 1999 and April 2003 at three centres with specific expertise in the treatment of psychiatric illness during pregnancy. The participants had a history of major depression prior to pregnancy, were less than 16 weeks’ gestation, and were currently or recently (less than 12 weeks prior to last menstrual period) receiving antidepressant medication.

The researchers found that 43% of women in the sample relapsed during pregnancy, and half of those relapsed during the first trimester. Among women who maintained their medication throughout the pregnancy, 26% relapsed compared with 68% of those who discontinued their medication.

Health industry news from the publishers of Medical Chronicle 01 February 2006

The Comorbidity of Major Depression and Anxiety Disorders

Recognition and Management in Primary Care
Robert M. A. Hirschfeld, M.D.

Depression and anxiety frequently co-occur, especially in primary care settings. These co-occurrences manifest themselves in several ways and have different clinical courses. This review was written to help the clinician to identify what is and is not important in the diagnosis and treatment of patients with comorbid depression and anxiety in the primary care setting. The scope of this review is limited to major depression and not other forms of depression such as bipolar depression or dysthymic disorder. Literature was reviewed by 2 methods:

(1) a MEDLINE search (1980–2001) using key words depression, depressive disorders, and anxiety disorders; comorbidity was also searched with individual anxiety diagnoses; and
(2) direct search of psychiatry, primary care, and internal medicine journals over the past 5 years.

The scope and impact of depression and anxiety disorders worldwide are overwhelming. The watershed Global Burden of Disease study found that major depression ranked fourth among all medical illnesses in terms of its disabling impact on the world population. 1,2 The authors
estimated that by the year 2020 depression would be second only to ischemic heart disease. Anxiety disorders rank close behind major depression, contributing additional disability.

The prevalence of depressive and anxiety disorders in primary care settings is high. Between 10% and 20% of adults in any given 12-month period will visit their primary care physician during an episode of mental illness (although frequently not because of the episode). Depression and anxiety disorders contribute to the majority of those visits. If unrecognized and undiagnosed, depression and anxiety disorders contribute to high medical utilization in the primary care setting. Twenty-four percent of high utilizers (the top 10%) have been found to suffer from current major depression and 22%, from an anxiety disorder.

In primary care, presenting complaints for behavioral problems are more likely to be somatic than psychological. Back pain, chest pain, shortness of breath, heart palpitations, problems with sleep or appetite, and fatigue are among the most frequent presenting symptoms.

Although much work still needs to be done to increase awareness of depression and anxiety, the last decade has witnessed enormous progress in both the recognition and management of these disorders, especially in the primary care setting, which has long been recognized as the she is a bad wife and mother. She is no longer interested in sex. Lately, the patient admits that she does not really care that much about anything she has lost all of her interests.


Bipolar Depression (An Interview with Robert Hirschfeld, MD)

Editor’s Note:

Surveys indicate that up to 70% of patients with bipolar disorder are incorrectly diagnosed with unipolar or major depression. Because traditional antidepressant therapy can destabilize this population, misdiagnosis thus has significant consequences. To reduce the incidence of misdiagnosis, Robert Hirschfeld, MD, and his colleagues developed the Mood Disorder Questionnaire (MDQ), a brief survey to detect past episodes of mania in patients with depression.

On behalf of Medscape, Jessica Gould interviewed Dr. Hirschfeld about this instrument. Dr. Hirschfeld is the Titus Harris Chair of the Department of Psychiatry and Behavioral Sciences at the University of Texas Medical Branch in Galveston.

Medscape: What prompted you to develop the questionnaire for bipolar disorder?

Dr. Hirschfeld: A bipolar screening tool was actually prompted by a man named Sean Nolan, who worked for Avis Pharmaceuticals; he suggested that we needed a screening instrument for bipolar disorder. At the time, I thought it was foolish and that it was obvious that we didn’t need it. How wrong I was!

Medscape: Why did you think it was foolish, and what led you to change your mind?

Dr. Hirschfeld: At the time we were conceptualizing the Mood Disorder Questionnaire (MDQ), I believed that mental health professionals rarely missed the diagnosis of bipolar disorder. Research findings, including those from my own studies, proved that opinion wrong.

Medscape: How did you formulate the questionnaire?

Dr. Hirschfeld: I put together a small work group. We came up with a set of questions drawn from the DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition), from our clinical experience, and from research interviews that were created to diagnose bipolar disorder.

Then we compiled them and tested them in our clinics in a group of patients who had bipolar and other psychiatric disorders. We used various psychometric techniques to devise the 13 yes/no questions that are now widely in use. Since that time, we’ve carried out a number of validations in other populations.

We conducted the original validation in several psychiatric clinics that tended to specialize in mood disorders. We subsequently tested it in a large nationwide community survey. This was a group, not of patients, but of citizens who were part of an ongoing epidemiologic survey.

We’ve also tested the MDQ in several primary care clinics, and it has been translated into a number of languages throughout the world. So it’s very widely used.

Medscape: When and how should providers use the questionnaire?

Dr. Hirschfeld: My recommendation is to give it to anyone who is going to be prescribed an antidepressant, especially to treat depression. Approximately 1 in 4 or 5 people who present with depression are going to have bipolar disorder in some form. You’re going to find quite a few people with bipolar simply by administering the questionnaire. Then, if you get a positive screen, you’ll want to evaluate the individual more carefully for bipolar disorder. Because simply getting a positive screen does not mean that you’ve got bipolar disorder.

Medscape: I can conceive of situations in which people without bipolar disorder might answer “yes” to several of your questions — sleeping patterns disrupted while cramming for an exam, the stress of a new job, or perhaps the elation of falling in love. How do you distinguish these cases from someone presenting with the symptoms of bipolar disorder?

Dr. Hirschfeld: It is true that many of the symptoms of mania are emotions people can experience for a variety of reasons other than having a psychiatric disorder. That’s why it’s important to conduct the clinical interview. In the clinical interview, we’re going to try to see whether these things co-occurred, whether they lasted for a significant period of time, and perhaps of greatest importance, whether they caused a problem.

Medscape: What constitutes a problem?

Dr. Hirschfeld: It could be a problem in a relationship, a problem in a job, a legal problem. Did they create some kind of a mess or cause dysfunction in any way? These are fundamental to the diagnosis of all psychiatric disorders, but it’s particularly an issue with bipolar disorder, because people who do have the disease make very bad decisions. Their judgment is impaired, and when they are at the far end of the spectrum, they can actually be delusional.

Medscape: I know that bipolar disorder is often accompanied by a high degree of denial. I would imagine it could be difficult to get such patients to fill out the questionnaire.

Dr. Hirschfeld: It’s not necessarily difficult to get them to fill out the questionnaire, but they may not regard things that happen to them to be a problem, especially if they are high at the time. An unfortunate lack of insight is really fundamental to the illness and just compounds the problems.

Medscape: How do you get around the problem of lack of insight?

Dr. Hirschfeld: The lack of insight presents a sometimes insurmountable barrier to initiating treatments and certainly to ongoing adherence to treatment. Often it is only after several episodes with devastating consequences that individuals begin to confront, in a realistic way, the fact of their illness and what they need to do to help improve their lives.

The MDQ has certainly been used by many family members to help demonstrate to individuals that they might have bipolar disorder. People may be able to see themselves in some of the answers to some of the questions raised.

Medscape: Can you envision similar questionnaires for other disorders?

Dr. Hirschfeld: Certainly the use of questionnaires, especially if they are brief and simple, can help identify problems that are frequent and that are frequently being missed.

Medscape: What kind of feedback have you received about the questionnaire within the psychiatric community of providers?

Dr. Hirschfeld: Most respond positively. There were some questions about sensitivity and specificity and so on. It is not a perfect instrument, to be sure. One of the problems with bipolar disorder is that people can answer one way today and then another way at another time.

Medscape: What are you working on now?

Dr. Hirschfeld: Well, we just completed a study that involved giving the MDQ to everyone who was arrested in Galveston County. It’s part of a screen that the police do. Everyone who gets arrested gets a medical screen. One of the things that police are interested in is identifying people who might be at risk for suicide and who have very significant medical problems.

The rates of bipolar disorder were somewhat lower than we expected. I expected it to be in the range of 10% to 20%, and I think that a possible reason it was below that range is, not because there is a low incidence of bipolar disorder among people being arrested, but rather because you get a huge amount of naysaying.

We are also looking at what happens to responses over time, at the stability of the instrument. We’re giving it to people at several time frames and then comparing their answers.

We just completed a version to compare the prevalence of bipolar disorder in Britain vs the United States. We came up with a slightly lower prevalence in Britain — under 3%. Our 2 nationwide community studies using the MDQ also suggest that the prevalence of bipolar disorder in Britain may be lower than that in the United States. This may not, in fact, be true, but may reflect differences in how people in England respond to questionnaires about manic behaviors compared with how people in the United States respond. We are hoping to replicate these studies in many other countries to help elucidate this. We are working specifically on programs in France, Spain, and Canada. Furthermore, we’re looking at the prevalence of bipolar disorder in adolescents. To
my knowledge, this is the first look at the prevalence of bipolar in adolescents in a community study.

This interview is published in collaboration with NARSAD, The Mental Health Research
Association, and is supported by an educational grant from GlaxoSmithKline.

Suggested Readings

  • Ettinger AB, Reed ML, Goldberg JF, Hirschfeld RM. Prevalence of bipolar symptoms in epilepsy vs other chronic health disorders. Neurology. 2005;65:535-540.
  • Hirschfeld RM, Bowden CL, Gitlin MJ, et al. Practice guideline for the treatment of patients with bipolar disorder (revised). Am J Psychiatry. 2002;159(Suppl):1-50.
  • Hirschfeld RM, Cass AR, Holt DC, Carlson CA. Screening for bipolar disorder in patients treated for depression in a family medicine clinic. J Am Board Fam Pract. 2005;18:233-39.
  • Hirschfeld RM, Williams JB, Spitzer RL, et al. Development and validation of a screening instrument for bipolar spectrum disorder: the Mood Disorder Questionnaire. Am J Psychiatry. 2000;157:1873-1875.

Robert M.A. Hirschfeld, MD, Titus Harris Chair; Professor and Chair, Department of Psychiatry and Behavioral Sciences, University of Texas Medical Branch, Galveston, Texas.

Disclosure: Jessica E. Gould, BA, has disclosed no relevant financial relationships.
Disclosure: Robert M.A. Hirschfeld, MD, has disclosed that he serves as an advisor or consultant to Abbott Laboratories, AstraZeneca, Bristol-Myers Squibb, Forest Laboratories, GlaxoSmithKline, Janssen, Eli Lilly & Company, Novartis, Organon, Inc., Pfizer, Shire, UCB Pharma, and Wyeth-Ayerst.

Medscape Psychiatry & Mental Health. 2006;11(1) ©2006 Medscape