A case for mixed depression with Bourdain

Mixed depression according to some researchers is rather common but for some reason people don't think of it when someone like Bourdain commits suicide. Perhaps the depression goes unrecognized since the person's behavior isn't consistent with depression and the hypomanic symptoms are not meeting some arbitrary threshold. According to Targum:

“Mixed” depression is a clinical presentation in which a patient meets the full criteria for MDD and, at the same time, has a mixture of other features that are consistent with hypomania or mania. However, when only two or three of these manic symptoms are present, the duration fails to meet current criteria for hypomania (4 days) or mania (7 days), and therefore the diagnosis does reach the full criteria for a hypomanic or manic episode.²  

One hypomanic symptom would be Bourdain's restlessness and consistent traveling in search of the perfect meal in Parts Unknown. This is at odds with depression but his affect while doing so often seemed depressed to me. His commentary for the most part rather acerbic/cynical but punctuated with periods of levity.

A second sign of hypomanic symptoms was his suicide. It is fairly well known that suicide increases with mixed states. A mixed state is often a high energy state combined with a depressed mood. What constitutes high energy though is somewhat debatable. Most see it as an increase in physical activity which is productive but I contend from personal experience that one can have an extremely restless mind and be quite fatigued at the same time. In addition to the high energy there is often insomnia which might be attributed to stress or depression and not a symptom of hypomania.

A third sign of bipolar disorder was that Bourdain also seemed irritable which is another symptom of hypomania but most would probably see it as consistent with agitated depression. Depressed people can be irritable but it is usually not combined with excess goal orientated energy.

A fourth indication of bipolar was he was an ex addict. Addiction is more common among people with bipolar and could be due to a need to medicate or control an agitated and unhappy mind. What is unknown is had he relapsed or was he taking any antidepressants which might have precipitated the suicide. Antidepressants are known to aggravate bipolar depression and it is not a stretch to think they might have been involved.

A fifth sign was that he was married twice and in a relationship with a third woman. Multiple marriages are more consistent with bipolar tendencies. Irritability, grandiosity and restlessness is obviously going to cause more conflict.

And finally, his success as author, journalist and chef supports someone with a tendency towards hypomania. On average individuals with bipolar tend to be more productive and creative people which he certainly was. He wrote numerous books and was a famous TV personality.

Symptoms can fluctuate to quite a degree in bipolar disorder/unipolar depression and if that happens within a day this is often just attributed to what is know as diurnal variation. Personally, I experienced a very pronounced variation when younger. Somewhat of a mixed state early in morning, around 3am- 6am and then an improvement as the day went on. At night I often felt much better and was considerably more productive. This was considered as still consistent with Dysthymia according to my doctor.

What really seems to confound a diagnosis of "mixed depression" or bipolar disorder is how one evaluates what is "high energy". Is it always productive or can it be nonproductive as in anxiety? Dr. Phelps is one doctor who challenges how excessive energy is evaluated. How can one measure a racing mind which can occur in mania or depression with mixed features. It sounds like it often depends on self report and a rather subjective evaluation of a patient's symptoms.

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.