Question:
Signs of major depression not so clearly defined?
Answer:
Until recently it was believed that no more than 1% of the general
population has bipolar disorder. Emerging transatlantic data are
beginning to provide converging evidence for a higher prevalence of up
to at least 5%. Manic states, even those with mood-incongruent
features, as well as mixed (dysphoric) mania, are now formally included
in both ICD-10 and DSM-IV. Mixed states occur in an average of 40% of
bipolar patients over a lifetime; current evidence supports a broader
definition of mixed states consisting of full-blown mania with two or
more concomitant depressive symptoms. The largest increase in
prevalence rates, however, is accounted for by 'softer' clinical
expressions of bipolarity situated between the extremes of full-blown
bipolar disorder where the person has at least one manic episode
(bipolar I) and strictly defined unipolar major depressive disorder
without personal or family history for excited periods. Bipolar II is
the prototype for these intermediary conditions with major depressions
and history of spontaneous hypomanic episodes; current evidence
indicates that most hypomanias pursue a recurrent course and that their
usual duration is 1-3 days, falling below the arbitrary 4-day cutoff
required in DSM-IV. Depressions with antidepressant-associated
hypomania (sometimes referred to as bipolar III) also appear, on the
basis of extensive international research neglected by both ICD-10 and
DSM-IV, to belong to the clinical spectrum of bipolar disorders.
Broadly defined, the bipolar spectrum in studies conducted during the
last decade accounts for 30-55% of all major depressions. Rapid-
cycling, defined as alternation of depressive and excited (at least
four per year), more often arise from a bipolar II than a bipolar I
baseline; such cycling does not in the main appear to be a distinct
clinical subtype - but rather a transient complication in 20% in the
long-term course of bipolar disorder. Major depressions superimposed on
cyclothymic oscillations represent a more severe variant of bipolar II,
often mistaken for borderline or other personality disorders in the
dramatic cluster. Moreover, atypical depressive features with reversed
vegetative signs, anxiety states, as well as alcohol and substance
abuse comorbidity, is common in these and other bipolar patients. The
proper recognition of the entire clinical spectrum of bipolarity behind
such 'masks' has important implications for psychiatric research and
practice. Conditions which require further investigation include: (1)
major depressive episodes where hyperthymic traits - lifelong hypomanic
features without discrete hypomanic episodes - dominate the intermorbid
or premorbid phases; and (2) depressive mixed states consisting of few
hypomanic symptoms (i.e., racing thoughts, sexual arousal) during full-
blown major depressive episodes - included in Kraepelin's schema of
mixed states, but excluded by DSM-IV. These do not exhaust all
potential diagnostic entities for possible inclusion in the clinical
spectrum of bipolar disorders: the present review did not consider
cyclic, seasonal, irritable-dysphoric or otherwise impulse-ridden,
intermittently explosive or agitated psychiatric conditions for which
the bipolar connection is less established. The concept of bipolar
spectrum as used herein denotes overlapping clinical expressions,
without necessarily implying underlying genetic homogeneity. In the
course of the illness of the same patient, one often observes the
varied manifestations described above - whether they be formal
diagnostic categories or those which have remained outside the official
nosology. Some form of life charting of illness with colored graphic
representation of episodes, stressors, and treatments received can be
used to document the uniquely varied course characteristic of each
patient, thereby greatly enhancing clinical evaluation.
Based on the author's work and that of collaborators, as well as other
contemporaneous research, this article reaffirms the existence of a
broad bipolar spectrum between the extremes of psychotic manic-
depressive illness and strictly defined unipolar depression. The
alternation of mania and melancholia beginning in the juvenile years is
one of the most classic descriptions in clinical medicine that has come
to us from Greco-Roman times. French alienists in the middle of the
nineteenth century and Kraepelin at the turn of that century formalized
it into manic-depressive psychosis. In the pre-DSM-III era during the
1960s and 1970s, North American psychiatrists rarely diagnosed the
psychotic forms of the disease; now, there is greater recognition that
most excited psychoses with a biphasic course, including many with
schizo-affective features, belong to the bipolar spectrum. Current data
also support Kraepelin's delineation of mixed states, which frequently
take on psychotic proportions. However, full syndromal intertwining of
depressive and manic states into dysphoric or mixed mania--as
emphasized in DSM-IV--is relatively uncommon; depressive symptoms in
the midst of mania are more representative of mixed states. DSM-IV also
does not formally recognize hypomanic symptomatology that intrudes into
major depressive episodes and gives rise to agitated depressive and/or
anxious, dysphoric, restless depressions with flight of ideas. Many of
these mixed depressive states arise within the setting of an attenuated
bipolar spectrum characterized by major depressive episodes and soft
signs of bipolarity. DSM-IV conventions are most explicit for the
bipolar II subtype with major depressive and clear-cut spontaneous
hypomanic episodes; temperamental cyclothymia and hyperthymia receive
insufficient recognition as potential factors that could lead to
switching from depression to bipolar I disorder and, in vulnerable
subjects, to predominantly depressive cycling. In the main, rapid-
cycling and mixed states are distinct. Nonetheless, there exist
ultrarapid-cycling forms where morose, labile moods with irritable,
mixed features constitute patients' habitual self and, for that reason,
are often mistaken for "borderline" personality disorder. Clearly, more
formal research needs to be conducted in this temperamental interface
between more classic bipolar and unipolar disorders. The clinical
stakes, however, are such that a narrow concept of bipolar disorder
would deprive many patients with lifelong temperamental dysregulation
and depressive episodes of the benefits of mood-regulating agents.
Will you please stop calling me bipolar because I disagree with your
bullshit ideas on meds Larry? Ive told you over and over again that you
dont belong on here. There is only ONE way to treat major depression
and that is with antidepressant meds and ECT. Plus Ive already been on the other classes of psych meds like mood
stabilizers and anti-psychotics Larry. They all bring me down and make
me more depressed. The only thing that helps me is antidepressants and
exercise.
I would appreciate it if you would take your psychologist self and hit
the road. Psychologists are NOT Medical Doctors and they cannot
diagnose people.
