- Bouts of anxiety and depression are typically observed before episodes of hypomania or mania in bipolar disorder.
- The context and history of depression must be evaluated carefully to reduce diagnostic and treatment confusion.
- Abrupt drops in academic performance, increased substance abuse, and behavioral difficulties may be clues to bipolar disorder or schizophrenia.
Many young people today are being treated for depression — and experience temporary relief from depression — with psychotherapy and medication. Yet for many individuals with bipolar disorder, the most common initial presentations are anxiety and depression. These disorders can present themselves years before a person experiences an episode of mania — the hallmark symptom of bipolar disorder.
A large meta-analysis looking at mental health studies across the world found that the median age of onset for an anxiety disorder is 17 years old and 26 years old for depression. The median age of onset of bipolar disorder is 33 years old1. Awareness of later onset risks around bipolar disorder is critical to avert a path that, while offering temporary relief, could ultimately derail the diagnosis and treatment of the more serious illness.
A Student’s Troubling Experience
Consider an 18-year-old college freshman who enters psychotherapy treatment provided by the on-campus mental health clinic to treat his depressive symptoms. Although his first semester started off well, he began to fall behind in his academic work and eventually stopped going to his classes. In high school, he was a B+/A- student who was well-liked by his peers and was known to have a bright and cheerful disposition.
Upon evaluation, he was absent of emotional facial expression. He stated that he felt worthless with low self-esteem, and anxious most of the day (claiming it as the reason he smoked marijuana). He frequently pondered the meaning of life and began questioning his belief in God. He said that he felt like life was not worth living, and after telling this to his parents, they recommended that he seek psychotherapy to help him develop better coping skills.
This initial treatment reduced his anxiety slightly. Yet he was not able to regain his motivation, leading him to drop out of school. While at home, he remained in his room smoking marijuana heavily, playing video games for hours on end, and spending most of his day sleeping. Suddenly, he said that he no longer felt safe and decided to take a trip across the country to see a “safer” family member. His parents called 911 and had him brought to the emergency room, where he was given a serotonin-selective reuptake inhibitor (SSRI) for his depression and sent home after a day.
Looking Beyond Initial Treatment
The severity of the young man’s depressive episode might foreshadow more than initially meets than eye. Studies suggest that an early age of symptom onset in bipolar disorder is associated with a longer delay to treatment, greater severity of depression, and higher levels of comorbid anxiety and substance abuse2.
How can we know whether anxiety and depressive symptoms can be helped by psychotherapy or if they require a more thorough psychiatric evaluation to understand a more complex root cause? The symptoms that present themselves may not be adequate to make a diagnosis. It is therefore important to consider important questions prior to making an appointment with a mental health provider and to determine the nature of the evaluation and treatment required.
1. Did the person lose their coping skills, or did they never really develop them?
The loss of coping skills can point towards an acute phase of mental illness and requires a more urgent psychiatric evaluation, whereas a longstanding lack of coping skill acquisition could point more towards a neurodevelopmental disorder (such as attention deficit hyperactivity disorder or learning disability). Psychiatric evaluations are important in neurodevelopmental disorders, particularly in those who have ADHD. However, the urgency is not as high as acute illness states.
2. Is the person lagging in their academic work or job?
Because the person is usually not as aware that they may be in a state of illness, the first signs may only be seen through social and work settings. A person may attribute their loss of function to “stress” or other various reasons, but the decline in function is noticeable and is a shift from their normal functioning. This can be seen through missed assignments or absence from meetings or classes.
3. Is questioning existential purpose normal or is it a sign of depression? Are the person’s thoughts and opinions moving outside of what can be easily proven?
Most people question their existential purpose at various points in their lives. This could be a normal part of reflection about their next career or relationship direction. Some important existential questions can be related to religion and God. However, the answers to these questions are not easily proven. And, when existential questions remain at the forefront of a person’s mind and for longer than a few days, it could be a sign of depression or psychotic illness.
4. Is substance use becoming more frequent?
Substances of abuse are so named because people tend to consume them in high amounts. To start answering why some people are more prone to substance abuse than others, consider that they offer two main effects: 1) euphoria or calming and soothing and 2) disconnection from reality. Both effects may serve as a coping strategy for acute illness. An association between marijuana and psychosis (in depression, bipolar disorder, or schizophrenia) is well-established3. However, psychotic symptoms can be a result of intoxication, or a result of mental illnesses such as bipolar disorder and schizophrenia.
For our student, despite his access to psychotherapy and medication, he remained at high risk at the point we left him. He was experiencing coping and academic performance issues at odds with his history. He is questioning his purpose and reason for existence, and self-soothing through drug abuse.
With the knowledge that his depression is unusually severe given his age, there is power in knowing that his symptoms might be a canary in the coal mine signaling bipolar or another disorder. Asking the right questions, even after this initial treatment, could change how he is treated. The only way to determine a diagnosis in such a case is a thorough biological, psychological, and social examination that assesses different factors contributing to his symptoms.
In my upcoming posts in this series, I will further explore the value of the biopsychosocial approach to diagnosing and treating depression and bipolar disorder in different patients.
 Solmi, M., Radua, J., Olivola, M. et al. Age at onset of mental disorders worldwide: large-scale meta-analysis of 192 epidemiological studies. Mol Psychiatry 27, 281–295 (2022). https://doi.org/10.1038/s41380-021-01161-7
 Joslyn C, Hawes DJ, Hunt C, Mitchell PB. Is age of onset associated with severity, prognosis, and clinical features in bipolar disorder? A meta-analytic review. Bipolar Disord. 2016; 18(5): 389- 403. https://doi.org/10.1111/bdi.12419