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Dr. Bob is Robert Hsiung, MD,
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Posted by jrbecker on July 21, 2004, at 9:28:08
http://pn.psychiatryonline.org/cgi/content/full/39/14/24
Psychiatric News July 16, 2004
Volume 39 Number 14
© 2004 American Psychiatric Association
p. 24
--------------------------------------------------------------------------------Clinical & Research News
Major Depression May Be Relative of Bipolar Disorder
Joan Arehart-Treichel
Patients with recurrent major depression may experience several manic or hypomanic symptoms throughout their lifetimes, suggesting that major depression and bipolar depression are not two distinct disorders.Are major depressive disorder and bipolar disorder related? There are various reasons to think so. For instance, bipolar disorder is sometimes misdiagnosed as recurrent major depressive disorder. Bipolar disorder and severe major depression are also known to aggregate in families, and this overlap appears to be due to genetic factors.
And now still more reason to believe that major depression and bipolar disorder are related comes from a study conducted by Italian and American psychiatric researchers. It found that subjects with recurrent major depression experienced a substantial number of manic/hypomanic symptoms over their lifetimes.
The principal author of the study is Giovanni Cassano, M.D., director of the department of psychiatry, neurobiology, pharmacology, and biotechnology at the University of Pisa. Results of the study appeared in the July American Journal of Psychiatry.
Recruited to participate in the study were 117 patients with remitted recurrent major depression and 106 patients with bipolar I disorder. Patients in both groups included inpatients and outpatients from nine academic settings in Italy.
The investigators confirmed all of the subjects' diagnoses with the Mini International Neuropsychiatric Interview, a brief structured interview designed to diagnose Axis I disorders and antisocial personality disorder according to DSM-IV and ICD-10 criteria. The reliability of this instrument has proven to be excellent in multicenter clinical trials and in epidemiological and clinical studies.
The subjects were also given the Structured Clinical Interview for the Spectrum of Mood Disorders. It was developed by Italian and American psychiatrists, including several of the authors of this study, to assess subjects' lifetime symptoms, traits, and lifestyles that characterize threshold and subthreshold mood episodes as well as temperamental features related to mood dysregulation.
Traditional Dichotomy Challenged
First, the subjects with recurrent major depression reported that they had experienced a substantial number of manic or hypomanic symptoms over their lifetimes.
"The presence of a significant number of manic/hypomanic items in patients with recurrent major depression seems to challenge the traditional dichotomy of unipolar-bipolar disorder and bridges the gap between these two categories of mood disorders," the researchers stated in their study report.
Second, in both patients with recurrent major depression and patients with bipolar I disorder, the number of manic/hypomanic items reported was related to the number of depressive items reported, suggesting a link between the two.
And finally, the more manic/hypomanic items that the recurrent major depression subjects reported, the greater the likelihood that they also reported having suicidal ideas or paranoid or delusional thoughts, such as "feeling as if others were causing all of your problems," "feeling surrounded by hostility," or "everyone is talking about you," at some point in their lives.
"This latter result," the researchers wrote, "corroborates the observation that the presence of even mild manic symptoms may change a depressive presentation into a mixed presentation and increase the likelihood of psychotic symptoms."
These results imply, said the researchers, that major depression and bipolar disorder are related and that the psychiatric field "would benefit from a unitary and continuous approach to the assessment of both manic/hypomanic and depressive symptoms."
Or as Cassano told Psychiatric News, the results "provide evidence that a substantial proportion of patients with unipolar depression experience manic/hypomanic symptoms during their lifetime and that these symptoms are associated with a more negative prognosis (suicidality, paranoid ideation). Because this association is similar to the one found in bipolar patients, we conclude that unipolar and bipolar disorders are not two discrete entities, but should be considered a unitary phenomenon, to be studied using a longitudinal perspective."
Poorer Prognosis Expected
When asked about the clinical implications of the results, Cassano said, "The assessment of manic-hypomanic symptoms in so-called unipolar patients is probably important in predicting a poorer prognosis. A large clinical trial is under way in Pittsburgh and Pisa to determine whether manic/hypomanic symptoms in unipolar patients characterize a distinct phenotype showing a differential response to treatment with SSRI, interpersonal therapy, or a combination of the two."
David Kupfer, M.D., chair of psychiatry at the University of Pittsburgh and one of the study authors, told Psychiatric News, "The implications of this research for clinical psychiatrists are important since many difficult-to-treat patients are difficult because they have a `dose' of unipolar and bipolar features. While they are often diagnosed with non-bipolar depression, there is a significant degree of subsyndromal lifetime bipolar features that reduce the usual level of therapeutic responsiveness that can be expected with SSRI or other interventions used to treat depression. This may also be true in those individuals who do not respond to targeted psychotherapy alone (interpersonal therapy or cognitive behavioral therapy). Many of these individuals may require treatment sequencing or combination treatments to achieve full recovery."
The study, "The Mood Spectrum in Unipolar and Bipolar Disorder: Arguments for a Unitary Approach," is posted online at <http://ajp.psychiatryonline.org/cgi/content/full/161/7/1264>;.
Am J Psychiatry 2004 161 1264[Abstract/Free Full Text]
Posted by Pfinstegg on July 22, 2004, at 13:12:18
In reply to Major Depression May Be Relative of Bipolar Disord, posted by jrbecker on July 21, 2004, at 9:28:08
Thank you! I really appreciate the articles you post here- you keep us all up-to-date!
Posted by SLS on July 23, 2004, at 18:00:06
In reply to Major Depression May Be Relative of Bipolar Disord, posted by jrbecker on July 21, 2004, at 9:28:08
Perhaps unipolar and bipolar disorders are not so much related etiologically as they are just similar in outward appearance. When does a unipolar become a bipolar? The moment he displays mania or hypomania? Right? The point is, he was never unipolar. I think the diagnosticians get a little too nutty with the way they try to enforce the rigid definitions contained in the DSM.
I bet there is a tendency for bipolar depression to be subtly, but consistently different from unipolar depression in its expression. Basically, I think bipolar depression resembles anergic atypical unipolar depression except that there is no mood reactivity.
Some people with bipolar disorder might never express mania. However, their depression might not respond sufficiently to years of antidepressant treatment until someone gets the bright idea of adding a mood stabilizer.
I don't know. I have an open mind.
- Scott
Posted by TJO on July 24, 2004, at 6:22:30
In reply to Re: Major Depression May Be Relative of Bipolar Disord, posted by SLS on July 23, 2004, at 18:00:06
> Perhaps unipolar and bipolar disorders are not so much related etiologically as they are just similar in outward appearance. When does a unipolar become a bipolar? The moment he displays mania or hypomania? Right? The point is, he was never unipolar. I think the diagnosticians get a little too nutty with the way they try to enforce the rigid definitions contained in the DSM.
>
> I bet there is a tendency for bipolar depression to be subtly, but consistently different from unipolar depression in its expression. Basically, I think bipolar depression resembles anergic atypical unipolar depression except that there is no mood reactivity.
>
> Some people with bipolar disorder might never express mania. However, their depression might not respond sufficiently to years of antidepressant treatment until someone gets the bright idea of adding a mood stabilizer.
>
> I don't know. I have an open mind.
>
>
> - Scott
>
>
Hi Scott,You know someone could make a case for bipolar disorder being related to schizophrenia too since some people hear voices and see things while they are in a psychotic state.
Tam
Posted by SLS on July 24, 2004, at 7:33:53
In reply to Re: Major Depression May Be Relative of Bipolar Disord, posted by TJO on July 24, 2004, at 6:22:30
Hi Tammy.
> You know someone could make a case for bipolar disorder being related to schizophrenia too since some people hear voices and see things while they are in a psychotic state.
Many people have made that case. Basically, I think bipolar disorder and schizophrenia start out in very different areas of the brain and/or involve very different biological processes. However, both disease processes eventually affect the same brain circuits responsible for executive function and affect, which are located in the frontal and prefrontal cortical areas. Both illnesses will express similar symptoms. Among the more pursuasive arguments in favor of there being no relationship between schizophrenia and bipolar disorder is the fact that mood stabilizers have no therapeutic effect in schizophrenia.
- Scott
Posted by BarbaraCat on July 24, 2004, at 12:54:28
In reply to Re: Major Depression May Be Relative of Bipolar Disord, posted by SLS on July 23, 2004, at 18:00:06
> I bet there is a tendency for bipolar depression to be subtly, but consistently different from unipolar depression in its expression. Basically, I think bipolar depression resembles anergic atypical unipolar depression except that there is no mood reactivity.
**Not my experience of it, Scott. My depressions have gone all over the spectrum. I occasionally get the 'oh what's the use' anergic gray blob depression, but what I've come to recognize as the pure bipolar form is a bleak, very weird, agitated and psychotically nightmarish experience that can sometimes last for months at a time. The best way to describe it is Edgar Allen Poe on a bad acid trip. Mixed states, and extremely mood reactive. I have a particuarly severe form of bipolar depression and not all Bipolars get mixed states, thankfully. At it's worst, it is schizoaffective, so something is triggering different parts of my brain to produce quite variable states. My point is that no generalizations can be made. Bipolar goes so wildly over the map that it amazes me that all these symptoms can be lumped under one umbrella.
>
> Some people with bipolar disorder might never express mania. However, their depression might not respond sufficiently to years of antidepressant treatment until someone gets the bright idea of adding a mood stabilizer.**I didn't consider myself bipolar until I started going way back and reframing all those wild and crazy times, all the unfinished projects, the mystical experiences of the Divine, the irritability and insomnia, and thought hmmmmm, well maybe. But the proof in the pudding is how worse I was getting on solo antidepressants and how dramatically lithium changed my life. I don't know, maybe what it comes down to is that if you're depressed and taking an antidepressant, chances are that antidepressant will eventually poop out without a mood stabilizer. Maybe a mood stabilizer should be given, de rigeur, along with an AD.
Here's a very good site with great info on bipolar. You can spend days following the links.
http://www.psycheducation.org/
- BarbaraCat
Posted by SLS on July 24, 2004, at 18:05:50
In reply to Re: Major Depression May Be Relative of Bipolar Disord » SLS, posted by BarbaraCat on July 24, 2004, at 12:54:28
Hi Barbara Cat.
> > I bet there is a tendency for bipolar depression to be subtly, but consistently different from unipolar depression in its expression. Basically, I think bipolar depression resembles anergic atypical unipolar depression except that there is no mood reactivity.
> **Not my experience of it, Scott.I am probably guilty of generalizing in part because the description fits my experience, but much of what I have encountered in the literature describes bipolar depression as resembling atypical unipolar depression in that it usually presents with anergia, psychomotor retardation, hypersomnia, hyperphagia, and reverse diurnal variation (relative to classically defined endogenous depression).
> My depressions have gone all over the spectrum. I occasionally get the 'oh what's the use' anergic gray blob depression,
When you are in this state, does it resemble atypical depression? Is morning your best time or your worst time?
> but what I've come to recognize as the pure bipolar form is a bleak, very weird, agitated and psychotically nightmarish experience that can sometimes last for months at a time.
Perhaps this is a mixed-state and not pure depression.
> The best way to describe it is Edgar Allen Poe on a bad acid trip. Mixed states, and extremely mood reactive.
How do you describe your mood reactivity? Can you be brought out of your depression temporarily if something good happens?
> My point is that no generalizations can be made.
I'm not convinced of that yet. :-) I do understand that the spectrum of presentations is highly variable, but I think the wide range of recipes include a relatively small number of ingredients.
> > Some people with bipolar disorder might never express mania. However, their depression might not respond sufficiently to years of antidepressant treatment until someone gets the bright idea of adding a mood stabilizer.
> **I didn't consider myself bipolar until I started going way back and reframing all those wild and crazy times, all the unfinished projects, the mystical experiences of the Divine, the irritability and insomnia, and thought hmmmmm, well maybe. But the proof in the pudding is how worse I was getting on solo antidepressants and how dramatically lithium changed my life.This is exactly why I think it is so important to diagnose accurately bipolar depression and differentiate it from unipolar depression if it is at all possible as soon as possible. Perhaps there are some common, although subtle, features of bipolar depression that can be recognized or generalized in a majority of cases. I hope so.
> I don't know, maybe what it comes down to is that if you're depressed and taking an antidepressant, chances are that antidepressant will eventually poop out without a mood stabilizer.
Gosh, I hope not. I don't think one can use the communities of people posting on Internet websites like this one as a reflection of the total population of people being treated for depression. I think the population here on PB is skewed towards people who have failed treatment, and it would be difficult to extrapolate from it to what degree "poop-out" occurs generally.
> Maybe a mood stabilizer should be given, de rigeur, along with an AD.
What does "de rigeur" mean?
> Here's a very good site with great info on bipolar. You can spend days following the links.
>
> http://www.psycheducation.org/Thanks for the link. I really, really hope I'm right about the bipolar depression thing. If there is any way to tease out a tell-tale symptom profile, it will save a lot of anguish. Of course, finding a bioligical test would be even better.
- Scott
Posted by BarbaraCat on July 24, 2004, at 23:52:31
In reply to Re: Major Depression May Be Relative of Bipolar Disord » BarbaraCat, posted by SLS on July 24, 2004, at 18:05:50
> Hi Scott,
>
> When you are in this state, does it resemble atypical depression? Is morning your best time or your worst time?
>
**I don't really know what typical vs. atypical might be. I characterize unipolar depression as being more typical of low energy, low affect, low, low, low. But this hypo-everthing is more the description of 'atypical'. I have two forms of mood disorder. One is the 'Life sucks and then you die and I could give a sh*t' brand, the other is hopeless despair with high anxiety, the most extreme case being mixed states. Both kinds are worse in the morning, and get better throughout the day. Perhaps something to do with cortisol. My levels are mid-range, not high. But things get so much better in the evening that cortisol is the major thing that would seem to influence it.
>
> Perhaps this is a mixed-state and not pure depression.**Yes, it is a mixed state. But hard to distinguish from good old agitated depression with psychotic features. The only thing that tells me it's probably bipolar is my dramatic response to lithium and the aggravation from SSRIs.
> >
> How do you describe your mood reactivity? Can you be brought out of your depression temporarily if something good happens?**Very temporarily. However, if I won the lottery, I don't care what they say, I would be one happy camper. If that didn't work, at least I'd prefer to cry on a silk pillow than a ratty one.
>
> > My point is that no generalizations can be made.
>
> I'm not convinced of that yet. :-) I do understand that the spectrum of presentations is highly variable, but I think the wide range of recipes include a relatively small number of ingredients.**This got me started on a flight of theoretical fancy. If you have a few ingredients - say flour, butter and milk - you can make different kinds of foods. Cookies, cream sauce, shortbread. But they all have a similar taste. It's hard to get different flavors from the ingredients, just different textures and shapes. So, where was I going with this? Seemed important at the time.
>
>
> This is exactly why I think it is so important to diagnose accurately bipolar depression and differentiate it from unipolar depression if it is at all possible as soon as possible. Perhaps there are some common, although subtle, features of bipolar depression that can be recognized or generalized in a majority of cases. I hope so.**Me too. So many other symptoms are now being attributed to the bipolar spectrum that it's difficult, especially for someone whose memory and judgement is impaired. It was a major shock to finally recognize that I was bipolar since I couldn't remember myself as anything but depressed when the questions were asked. We have to come up with something better than a subjective quiz.
>
> >Gosh, I hope not. I don't think one can use the communities of people posting on Internet websites like this one as a reflection of the total population of people being treated for depression. I think the population here on PB is skewed towards people who have failed treatment, and it would be difficult to extrapolate from it to what degree "poop-out" occurs generally.
>
**Of the many people with whom I've been acquainted who have mood disorders, the poop-out rate from SSRIs is pretty dang high. A long-term run of the same med at the same dosage is the exception. I'm referring specifically to SSRIs, not the older ADs. Mood stabilizers are frequently given for 'AD augmentation' when they poop. Maybe just cut to the chase and prevent the poop by prescibing a MS along with the SSRI. Hey, an idea for some enterprising pharm company.
>
> What does "de rigeur" mean?**From Encarta: Required, strictly required by the current fashion or by etiquette ( formal ). [Mid-19th century. From French, literally “of strictness.”]
> >
> > http://www.psycheducation.org/
>
> Thanks for the link. I really, really hope I'm right about the bipolar depression thing. If there is any way to tease out a tell-tale symptom profile, it will save a lot of anguish. Of course, finding a bioligical test would be even better.
>
**I'm waiting for that StarTrek phaser thingy that Dr. Beverly Crusher employed. You'd think with all the billions we're spending to blow people up we could do better by our mental health. The psycheducation.org website has a pretty good questionnaire that works alot better than the DSM-IV, which is pretty worthless considering how differently this thing presents. Shoot, how many different forms of bipolar are there now? Last count I think we were up to 4 or 5. I can't even tell if I'm BP-I or II. It'll probably all turn out to be mercury toxicity. - BarbaraCat
This is the end of the thread.
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