Four day rule of hypomania questioned

Published by the American Psychiatric Association, the DSM-IV-TR provides a common language and standard criteria for the classification of mental disorders. (Photo credit: Wikipedia)

A group of researchers are questioning the validity of the four day hypomanic threshold needed for a diagnosis of bipolar II. The four day rule could potentially exclude a considerable number of individuals with bipolar II.

They found that 186 bipolar II disorder patients who met the 4-day criteria did not differ significantly from 315 patients whose manic episode lasted less than 4 days on a number of illness correlates on the Mood Swings Questionnaire (MSQ).
“Our study findings are strongly consistent with previous studies arguing that the clinical phenotype of [bipolar] II disorder (and its existence) is not dependent on a minimum duration of four days as imposed by DSM-IV and DSM-5, but further advanced by validation against a number of clinical correlates and not simply by examining phenomenological expression,” the researchers Gordon Parker (Prince of Wales Hospital, Sydney, Australia) and colleagues comment.
The only difference was that patients with brief manic episodes were more likely to rate manic symptoms as being less severe than those whose episodes lasted for 4 days. The average total MSQ scores were 49.6 and 57.0, respectively.

I personally have experienced a significant mood change for less than four days. It often occurred  over a a period of three days and the mood switches within a day were almost like clock work. Given the arbitrariness of the rule I'm not surprised by this study's finding.

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.

Treatment of insomnia also improves depression

Insomnia again (Photo credit: Foodie In Disguise)

"The new report, from a team at Ryerson University in Toronto, found that 87 percent of patients who resolved their insomnia in four biweekly talk therapy sessions also saw their depression symptoms dissolve after eight weeks of treatment, either with an antidepressant drug or a placebo pill — almost twice the rate of those who could not shake their insomnia. Those numbers are in line with a previous pilot study of insomnia treatment at Stanford."
"Dr. Carney acknowledged that the study was small — just 66 patients — and said a clearer picture should emerge as the other teams of scientists released their results."

This study is interesting and shows promise however there is a considerable  percentage of depressed people who over sleep rather than suffer from insomnia. In my case I have experienced a combination of the two-- insomnia at night and oversleeping during the day. Additionally, I noticed that if I went to bed earlier than usual I would be more likely to have insomnia. This latest theory doesn't explain this.

Other problems with the study were that it was on the small side and the tools for measuring depression are questionable. They didn't appear to use a test that was specific for depression but one that was specific to rumination and insomnia. Why not use the same test as other depression studies?

Related articles

• Have Researchers Discovered a Quick Fix for Depression? (psychologytoday.com)

Joanna Moncrieff and the anti-psychiatry movement

Recently I visited the Mad in America website and commented on an article and video by Joanna Moncrieff.

Moncrieff is a psychiatrist in the UK who has written a number of books against the use of drugs and the idea of a bipolar spectrum. Since we both appeared to have the same opinion regarding the efficacy of antidepressants I thought some exchange might be interesting. In a comment, I wrote that I wish I had taken medication sooner than I had and that anti-psychiatrists appear to be  in a hurry to normalize mental disorders despite the lack of evidence for many of them one way or the other. In response a man replied that I hadn't paid attention to the previous discussion and how disastrous all psychiatric drugs/labels are. Here is an excerpt from her article.

Professional interests drove the transformation of antipsychotics from special sorts of tranquilisers into so-called ‘magic bullets’ back in the 1960s. It was this idea that antipsychotics constituted a sophisticated and targeted treatment, rather than a chemical suppressant, that obscured their unpleasant, mind-altering effects, thus enabling the pharmaceutical industry to expand their use over recent years

Now, I can see pluses and minuses to psychiatry however the people on this site are quite black and white. I am willing to bet for every story of someone harmed by psychiatry there is at least one who feels like he/she was saved by it. It is true that many people are being treated with drugs they don't need and perhaps mislabeled but there certainly are people who desparately need drugs and some name to describe their problem. For some reason we expect psychiatry to perform on par with other medical specialties even though we still know very little about the brain.

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.

Rapid cycling and unipolar depression

I have experienced chronic depression for most of my life and additionally a type of "rapid cycling" that is dismissed for the most part by psychiatrists. My "rapid cycling" seemed to often occur with in one day(extreme diurnal variation) and over three or more days,  almost  a cycling within cycling. The cycling often appeared out of a substrate of chronic depression and the timing of the cycling was almost something one could set their watch to.  The extent of the mood switch was considerable, from a suicidal depression to a rather productive euthymic/hypomanic mood. To this day I am not sure what precipitated it.

PsychEducation is one site that discusses the possibility of cycles occurring within "unipolar" depression. This site also  mentions and demonstrates the possibility of mixed states occurring within various cycles when depression is subcatorgized into mood, activity, and intellect. One can, for example, have a low mood plus high activity which could equal irritability in many.

But patients do have other combinations of depression and hypomania, or mania -- not just the two worst phases together.  And they do have cycles shorter than 4 days.  The DSM can't really handle these variations, but the model shown here handles them very well.

Additionally, during this "cycling" the purity of  my depression would in turn effect the purity of the euthymia/hypomania. A "pure" depressive mood which meant low irritability/anxiety would often be accompanied, within the same day, by a pleasant and productive euthymic state.  The amplitude of the cycle was often predicted by the depression.  Prior to unusually high mood a unusually low depressive dip would often occur. Incidentally one of the most severe cycles occurred while taking Lithium.

I firmly believe that this cycling I experienced was unusual/abnormal however I am  not certain that it suggests bipolarity.  On the other hand it seems highly unlikely to me that on a molecular level, unipolar depression is dramatically different than bipolar disorder. I see the generally principle of "for every reaction there is an equal and opposite one.", operating in both disorders.

Anti-Psychiatry is simple minded

[youtube=http://www.youtube.com/watch?v=-P6_FwpVo_s&w=560&h=315]

According to this man in the video no known pathology exists in the mentally ill and consequently mental illness doesn't exist. What annoys me is that anti-psychiatrists believe that pathology or abnormality can only exist as either a lesion or something measured in the blood. I submit that they have an overly narrow view of pathology. Given the complexity of the human body numerous things could function abnormally. Migraine, for example, is a well accepted neurological disorder however neurologists aren't sure why migraines, much like mental illness, occur.

Another specific example of abnormality/pathology is the lack of circadian phase alignment between the sleep wake cycle and the melatonin cycle that exists in many depressed individuals. In SAD individuals the melatonin cycle is often delayed relative to the sleep wake cycle. This can be corrected by the use of bright light or melatonin supplements.  One particular study found a connection between the degree of depression and the lack of alignment between the two cycles.

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.

Probiotics can reduce symptoms of anxiety

I have always been interested in the relationship between diet and depression. Of all the food items yogurt is one that has consistently yielded the most improvement in my symptoms. Yogurt was unique in that it reduced my stress while at the same time increasing my motivation/energy. Additionally, I have also been interested the relationship between the vagus nerve and mood disorders. Recently there has been research that confirms my experience with diet and my intuition that the vagus nerve is somehow involved. This most recent study was performed on humans whereas previous studies were only on animals.

The vagus nerve connects the brain with the gut. A considerable percentage of the nervous system is devoted to the gut and to me that implies that something very important is going on there.

Scientists had already found that the brain sends signals to the gut, which is why stress and other emotions can contribute to gastrointestinal symptoms. The new study of 36 women show that the signals also travel the opposite way.

One method of research included brain imaging which is somewhat controversial. The fact that there was reduced activity in the part of the brain that deals with cognition agrees with previous studies on antidepressants which have shown decreased activity in the prefrontal cortex in responders. Perhaps the reduced activity in the areas associated with cognition were due to less anxious thoughts?

The women all had a functional magnetic resonance imaging (fMRI) brain scans before and after the one-month study period, which included asking the participants to match a series of faces showing angry or fearful expressions on a computer screen to other faces that appeared, the Daily Mail reported.

The women who ate the probiotic yoghurt had reduced activity in the part of the brain that handles aspects of cognition and emotion, while the women who ate non-probiotic yoghurt or no dairy showed either no change or an increase in activity, the results showed.

The study was relatively small and further studies are needed to confirm the connection.