Manic depressive controversies

An interesting lecture from Nassir Ghaemi on the bipolar spectrum concept. According to him unipolar and bipolar used to both be encapsulated under the phrase "Manic Depression". "Manic Depression" meant someone who either experienced severe depression or mania. "Bipolar disorder" is defined by an individual having both depression and mania/hypomania. The two phrases differ only by a conjunction....something I hadn't paid attention to before. Additionally, according to Kraepelin, a well known historic authority on the topic, individuals displaying mixed states were more common than the ones who had more pure states of either depression or mania. This has been noted more recently by other researchers such as Benazzi who published a number of articles about people who experience mixed depression.

Prevalence of mixed depression, a combination of depression and manic or hypomanic symptoms, is high in patients with bipolar disorders. Controlled studies are needed to investigate treatment of mixed depression; antidepressants can worsen manic and hypomanic symptoms, and mood stabilising agents might be necessary

My experience with mixed depression

While my depression has been more chronic I have experienced periods of time when it lifted and I felt normal and productive. There has also been a pattern to some of these "remissions". They often occurred during my menses and when ever I altered my sleep schedule to a minor degree. These remissions weren't long enough by DSM standards to qualify for hypomania however as Ghaemi states, the threshold for hypomania is to a large degree arbitrary.

I have noticed as well that my depressions didn't seem pure. They often included good amounts of irritability, insomnia, racing/crowded thoughts, hypersexuality, and a little grandiosity. Somewhat interestingly these symptoms tended to occur in the late evening to the early morning hours. This has been noted by some researchers who study ultra rapid cycling in children. Many clinicians would probably categorize my experience as someone who is experiencing a pronounced diurnal variation but I am reluctant to think that since diurnal variation usually means a slight remission of symptoms throughout the day without hypomanic-like symptoms.

Manic-depressive insanity in the sense here delimited is a very frequent disease. About 10 to 15 per cent, of the admissions in our hospital belong to it. The causes of the. malady we must seek, as it appears, essentially in morbid predisposition.-- Kraepelin

Ghaemi's historical perspective different from DSM

Ghaemi's perspective much like Kraepelin is based on the big picture of evidence and history, not mainly on image. At the moment the DSM-V seems to be ruled by people who are primarily concerned with the public's image of them. They mainly don't want to appear like they are over prescribing and over pathologizing normal behavior. The fact that bipolar is no longer grouped with major depression under Mood disorders is one example of their over reaction to anti-psychiatry.

In conclusion Dsythymia not all that accurate

As someone who has experienced chronic depression with a moderate severity, I am tired of hearing how my so called Dysthymia is defined as mild and at one time in the past, a personality issue. Bipolar disorder has been generally viewed as more incapacitating and more endogenous while unipolar depression is more neurotic. Ghaemi and Kraepelin's theories make sense to me in light of my experience with depression. It has been for the most part, quite incapacitating, miserable and briefly quite pleasant.

Certain factors predict bipolar disorder

A recent study found that there are a number of factors that increase the chance of having bipolar disorder.

Having at least four previous depressive episodes, suicidal acts, cyclothymic temperament, family history of bipolar disorder, substance abuse, younger age at onset and male gender all significantly and independently differentiated bipolar from unipolar disorders in the study of 2146 patients who initially presented with a first episode of major depression.
After an average of 13 years, 642 (29.9%) patients were diagnosed with bipolar disorder and 1504 (70.1%) were diagnosed with major depressive disorder.
Further statistical analyses showed that differentiation of future diagnoses of bipolar from unipolar disorder was maximal when between two and four risk factors were present per person.

I, myself, have about three. A family history of bipolar disorder, a younger age of onset and suicidal thoughts. The list specifies "suicidal acts" but I think suicidal thoughts could possibly count as well.

Why is bipolar disorder so popular?

One person in a Facebook group asked why is it popular to have bipolar disorder and other mental disorders among the young today? One possible answer is that bipolar disorder has been associated with an unusual amount of creativity,intelligence and wealth. Kay Jamison is partly responsible for this romantic notion. Other studies on the topic seem to support the theory regarding creativity and upward mobility but not so much intelligence. I think most people would rather be diagnosed with a disorder that is associated with excess productivity,creativity and wealth than depression or schizophrenia which hasn't been associated with any of these attributes. Here is an excerpt from one article regarding the topic:

We examined clinical features in 877 in- and outpatients affected by depression who were enrolled in psychopharmacological trials, subdivided according to Hollingshead's method into five social classes. The results showed that social class correlated significantly with the subtypes of mood disorders, with bipolar disorder being more frequent amongst the upper than the lower social classes. Furthermore, as already reported in other countries, social class appeared to influence the psychopathological pattern of depressive symptoms: somatization and anxiety were more frequent amongst the lower social classes, while psychic and cognitive symptoms were more common amongst the upper classes.

Another answer might be that the bipolar disorder which many are diagnosed with today isn't Bipolar I but Bipolar II. Bipolar II is less likely to be associated with psychosis which could make it more acceptable. In the past Bipolar disorder or Manic Depression was associated with a severe emotional disturbances, psychosis and a lack of treatment. No one wants a disease with no treatment.

A third possibility is that a small number of celebrities have been diagnosed with bipolar disorder and this could increase the popularity of the disorder. Catherine Zeta- Jones is one such celebrity who has been diagnosed with Bipolar II. She is obviously beautiful, popular and wealthy. Who wouldn't want to be associated with all that? Moncrief  who is a psychiatrist doesn't think Bipolar II patients need drugs and even questions the diagnostic category. Here is an excerpt from an article she wrote:

Bipolar disorder has become the ‘fashionable’ mental health diagnosis – helped, no doubt, by the fact that many celebrities, including Catherine Zeta-Jones and Stephen Fry, have said they, too, are sufferers.

A fourth possiblity is that artists such as Silvia Plath have been diagnosed with bipolar II. Artists share the angst that is more popular among younger people and popular artists are associated with increased social status/wealth.

A fifth possiblity is that bipolar disorder is more unusual than other mental illnesses with a percentage of around 2% of the population. It is also respected as more severe than say depression which is known as the "common cold" among doctors. This combined could make the person feel more unique and respected.

A sixth possibility and the most likely explanation is that Bipolar disorder is now seen as existing on a spectrum by a few bipolar experts. Additionally the concept of a spectrum gave pharmaceutical companies a new market for many of their highest priced medications which they market to psychiatrists and directly to the public.

In conclusion, I think it is popular to be slightly mentally ill but not so much that it is associated with loss of productivity and poverty. Poverty and isolation are what we all are trying to avoid.

Psychosis increases risk of bipolar disorder

Danish researchers have identified characteristics in people with psychotic depression that predict an increased risk for conversion to bipolar disorder.

The researchers analyzed data from several Danish registries to identify conversion to bipolar

disorder among patients with an initial diagnosis of unipolar psychotic depression between January 1995 and December 2007.
Among the 8588 patients included in the study, 609 were diagnosed with bipolar disorder (defined as a new diagnosis of hypomania, mania, mixed affective episode, or bipolar disorder) during follow-up, giving a conversion rate of 7.1%.
Comparison of patients who did and did not convert to bipolar disorder identified a range of differences, seven of which emerged as significant risk factors in multiple logistic regression analysis.
These were: younger age at onset of unipolar psychotic depression (adjusted odds ratio [AOR]=0.99 per year of increasing age); recurrent depression (AOR=1.02 per episode); living alone (AOR=1.29); receiving a disability pension (AOR=1.55); and the highest educational level being a technical education (AOR=1.55), short-cycle higher education (AOR=2.65), or medium-cycle higher education (AOR=1.75).
Further analysis of the impact of age at psychotic depression onset found that, compared with people aged 20 years or younger at onset, the AOR for bipolar disorder was 1.64 for those aged 20–29 years, 1.58 for age 30–39 years, 1.80 for age 40–49 years, 1.36 for age 50–59 years, 1.19 for age 60–69 years, 0.85 for age 70–79 years, and 0.40 for age 80 years or older.

The researchers said that in comparison to previous studies the risk was underestimated in this latest study. Interestingly people in the age group (40- 49) appear to have a greater risk than younger groups. I was under the impression for some time that bipolar disorder developed much earlier. Perhaps a greater fluctuation in hormones levels might increase the risk as well.

This study was of interest because I have experienced depression since age twelve and also experienced psychotic depression around age 14 and at 39. Despite experiencing some characteristics of bipolar disorder my doctors didn't think bipolar disorder was likely.

Is Bipolar disorder over diagnosed?

Joanna Moncrieff believes that psychiatrists are over diagnosing Bipolar disorder. Bipolar

disorder used to consist of extreme mood swings, hallucinations, bizarre beliefs and dramatic changes in energy which all occurred over weeks to months but now many "normal" people are receiving the label.

The manufacturers of rare antipsychotic medication have set about changing the meaning of this once rare and distinctive condition, expanding its boundaries beyond recognition so that 'bipolar disorder' has become a label that can be attached to a whole myriad of common personal difficulties, who then become legitimate targets for antipsychotic treatment.

I tend to still favor the idea of a mood spectrum since many traits in nature tend to be distributed in a bell curve like fashion. Extroversion/Introversion is one example of this. In the Myers and Briggs indicator extroversion/ introversion preferences are being tested for and when researchers looked at distibutions of scores of various preferences, most had a bell curve distribution. In this distribution most people fall on the borderline and the test somewhat arbitrarily says you are either an introvert or an extrovert.

I can see mood disorders being distributed in a similar fashion except this time perhaps the dichotomy would be instability/stability of mood. Many people would fall in the middle with a mild mood disturbance. What is questionable though are those Bipolar II individuals who border the "normal" area and one tail of the curve. Moncrieff would like to absorb the Bipolar II individuals into the normal part of the curve which would make Bipolar all or nothing however nature is rarely this black and white.

Is melancholia the only true type of depression?

According to an article in Psychology Today melancholic depression is the only true type of depression. The author claims that what passes for major depression today is equivalent to what people used to commonly refer to as "nerves" since many people who are depressed today don't necessarily feel sad. "Depressed" individuals today often demoralized, feel extremely fatigued, anxious, and have numerous physical complaints which can be treated with SSRIs while true depressives respond more to tricyclics and ECT.

There is a major problem with the diagnosis of "depression," and this is that it doesn't exist. There is such a thing as "melancholia," a very serious from of depression entailing risk of suicide and complete lack of pleasure in life. But, hey! for years this illness was called by its proper name, melancholia, and there is no reason why we can't continue to do so. Melancholia is, in fact, in the Diagnostic and Statistical Manual of the American Psychiatric Association, the famous "DSM," but as a subtype of major depression.

I agree that depression is vaguely defined and heterogeneous in comparison to other illnesses but melancholic depression is not the only type of depression. While sadness is often associated with melancholic depression one doesn't have to feel necessarily sad in order to qualify for the label. In fact I have heard many describe typical depression's mood as a lack of feeling when very severe. In my experience one's depression can change over the course of time as well. For example, when younger, I felt much greater sadness when a teenager than as an adult.

A second issue is one regarding symptoms. The symptoms that he lists as "nerves" are more commonly associated with atypical depression which are in turn is associated more often with bipolar depression , a type of depression with a significant genetic component. Other types of depression which are also often more atypical in nature are SAD and dysthymia.  While SAD is not as severe as melancholic depression, it has a close relationship with bipolar disorder and according to some studies it has unigue biological characteristics. Instead of an overactive HPA axis some have found an underactive HPA axis. According to research atypical depression while less severe seems just as legitimate as typical/melancholic depression.

When I researched various types of depression in the past it became apparent that the typical/atypical distinction while somewhat useful is oversimplified and features such as diurnal variation could change over the course of the episode. Additionally people often have a combination of both types of depression. Bipolar depression for example, often manifests itself as melancholic and atypical.  Melancholia imparts symptoms such as sadness, guilt and a motor impairments. The atypical  aspect can cause over sleeping, weight gain and extreme fatigue. In the end depression, while vague defined, has many faces that the author doesn't see or acknowledge.

Temperament could predict diagnosis and presenting symptoms

Your temperament could affect your diagnosis, presenting symptoms, and psychopathologic conditions. The results of a recent study indicate that distinguishing between the various temperaments of irritable, depressive, hyperthymic, and cyclothymic might be helpful.

The study researchers report that in their study of 129 patients, hyperthymic temperament showed a preferential association with bipolar I disorder (BD-I) and bipolar disorder not otherwise specified diagnoses (BD-NOS), whereas depressive temperament was more frequent in patients with bipolar II disorder (BD-II) and major depressive disorder (MDD).
Anxious and depressive temperaments were more frequent in current depressive and mixed episodes compared with manic ones, while irritable temperaments were most frequent in mixed episodes and in patients suffering from alcohol dependence compared with nondependent patients.

Additionally the study showed that hyperthymic temperaments protected against depressive and anxiety symptoms while it increased the susceptibility towards manic symptoms. In contrast depressive, irritable, and cyclothymic temperaments increased the susceptiblity towards psychopathologic sysmptoms such as somatization, and interpersonal sensitivity.

The authors conclude by suggesting that temperament be taken into consideration when diagnosing and treating. Given the small size of the study and cross sectional design, the study needs to be replicated by others.

Reassessing mood disorders

New research is causing researchers to reassess the DSM's view of mood disorders. Recently a Canadian researcher by the name of McIntyre performed a study that challenges the DSM model. McIntyre gave a neuroleptic, lurasidone, to two groups of bipolar patients. One group consisted of depressed individuals while the other consisted of those in a mixed state. Somewhat surprisingly the drug helped both equally which implies the two states aren't all that different.

Additional research by John Geddes, chairman of Oxford University's Department of Psychiatry at Oxford also supports the idea that the various states in bipolar disorder are more similar than different and that instability is the key feature. The idea of pure depression or pure mania in the DSM is idealistic and limits our understanding. In reality mood episodes usually consist of depressive and manic symptoms imposed on top of an unstable temperament instead of a completely euthymic mood.

This constant mood lability throws into doubt the entire DSM-based distinction between "bipolar" and "major depressive" disorders. It is instead consistent with Kraepelin's original view of manic-depressive insanity as a broad illness of recurrent mood episodes, irrespective of polarity (in other words, recurrent depression is manic-depressive illness even without classic manic episodes), in contrast to the current faith in bipolar disorder (mania is required) vs major depressive disorder (mania is absent).

Nassir Ghaemi concluded his article by suggesting that metanalysis on antidepressants efficacy are obscured by the fact that major depression is categorized too broadly and consequently there is too much heterogeneity. I believe he is suggesting that if depression is subcategorized to a greater degree the efficacy issue will be come much clearer. Perhaps antidepressants are more efficacious in one subtype than another? Additionally he suggests the opposite of most critics which is that bipolar disorder is too narrowly defined. I have had similar thoughts regarding the heterogeneity of depression and consequently I am in agreement.

Presence of 'activation syndrome' suggests bipolarity

When younger(in my twenties) I noticed that SSRIs initially gave me panic attacks and akathisia. I always had a suspicion that my depression had a degree of bipolarity about it and this study confirms it a little. Activation syndrome is more common among bipolar patients and it consists of the following symptoms:

The components of activation syndrome, as stated by the US Food and Drug Administration, are anxiety, agitation, panic attack, insomnia, irritability, hostility, aggressiveness, impulsivity, akathisia, and mania/hypomania. The syndrome is believed to flag suicidality risk in patients taking antidepressants.

If an individual has these symptoms it increases the chance of being bipolar by 3.27 fold.

On multivariate analysis, a bipolar diagnosis was one of only two variables independently associated with activation syndrome, increasing the likelihood 3.27-fold.

The other variable was experiencing a mixed depressed state which like a bipolar diagnosis, increases suicidality. In the past another mood researcher Benazzi, a proponent of 'mixed depression', believed that individuals with a few hypomanic traits such as irritability, insomnia and agitation while depressed were more likely to have bipolar disorder.

The other significant variable was being in a depressive mixed state, which raised the likelihood for activation syndrome 4.13-fold. The researchers note that a depressive mixed state is reportedly almost as common in patients with MDD who attempt suicide while on antidepressive treatment as it is in patients with bipolar disorder.

Given the small size of the study and the naturalistic/retrospective nature, further studies are needed to confirm the connection between activation syndrome and bipolarity.