Clinical picture and etiologic models of mixed states

Depression: discrete or continuous?

Elucidating the true structure of depression is necessary if we are to advance our understanding and treatment options. Central to the issue of structure is whether depression represents discrete types or occurs on a continuum. Nature almost universally operates on the basis of continuums, whereas human perception favors discrete categories. This reality might be formalized into a 'continuum principle': natural phenomena tend to occur on a continuum, and any instance of hypothesized discreteness requires unassailable proof. Research evidence for discrete types falls far short of this standard, with most evidence supporting a continuum. However, quantitative variation can yield qualitative differences as an emergent property, fostering the appearance of discreteness. Depression as a continuum is best characterized by duration and severity dimensions, with the latter understood in terms of depressive inhibition. In the absence of some degree of cognitive, emotional, social, and physical inhibition, depression should not be diagnosed. Combining the dimensions of duration and severity provides an optimal way to characterize the quantitative and related qualitative aspects of depression and to describe the overall degree of dysfunction. The presence of other symptom types occurs when anxiety, hypomanic/manic, psychotic, and personality continuums interface with the depression continuum.

Mixed-state bipolar I and II depression: time to remission and clinical characteristics

BACKGROUND

We compared the time to achieve remission and the clinical characteristics of patients with bipolar depressive mixed state and those with bipolar depressive non-mixed state.

METHODS

The subjects (N=131) were inpatients diagnosed between 2006 and 2012 with bipolar I or II disorder, depression and were classified into the following three groups: "pure depressive state" (PD, n=70), "sub-threshold mixed state" (SMX, n=38), and "depressive mixed state" (DMX, n=23). Diagnosis of a DMX was in accordance with Benazzi's definition: three or more manic symptoms in a depressive episode. The subjects' charts were retrospectively reviewed to ascertain the time to achieve remission from the index episode and to identify other factors, such as demographic and clinical characteristics, specific manic symptoms, and pharmacological treatment, that may have contributed to remission.

RESULTS

The time to achieve remission was significantly longer in the DMX (p=0.022) and SMX (p=0.035) groups than in the PD group. Adjustment for covariates using a Cox proportional hazards model did not change these results. Clinically, subjects with a DMX were more likely to have manic symptoms in the index episode, especially inflated self-esteem and psychomotor agitation than those in the PD.

LIMITATIONS

We investigated only inpatients and therefore could not comment on outpatients.

CONCLUSIONS

These findings showed that sub-syndromal manic symptoms in bipolar depression had different clinical characteristics and a more severe illness course, including a longer time to achieve remission, than did a pure depressive state.

Risperidone in the treatment of mixed state bipolar patients: results from a 24-week, multicenter, open-label study in Korea

AIMS

The goal of the present study was to evaluate the efficacy of risperidone combined with mood stabilizers for treating bipolar mixed state.

METHODS

The present study was a 24-week, open-label, combination, prospective investigation of the efficacy of risperidone in combination with mood stabilizers. Risperidone (1-6 mg/day) was given in combination with mood stabilizers in flexible doses according to clinical response and tolerability for 114 patients in mixed or manic episode.

RESULTS

Forty-four patients met our criteria for mixed state bipolar disorder and 70 met the criteria for pure mania. Mean age for the subjects was 39.0 +/- 11.0 years and 55.3% were female. The combination of risperidone with mood stabilizers significantly improved the scores on the Young Mania Rating Scale (YMRS), 17-item Hamilton Rating Scale for Depression (HAMD), 18-item Brief Psychiatric Rating Scale (BPRS), Global Assessment Scale (GAS), and Clinical Global Impression Scale for use in bipolar illness Severity (CGI-BP) at 24 weeks (P < 0.0001). Analysis of the YMRS, BPRS, GAS, and CGI-BP scores showed significant improvement in both the manic and mixed groups. The rate of response in YMRS scores was 84.2% (n = 96) and the rate of YMRS remission was 77.2% (n = 88) at week 24 in the total population. Seventy-four patients met both YMRS < or = 12 and HAMD < or = 7 at week 24 (64.9%). Risperidone was well tolerated, and adverse events were mostly mild.

CONCLUSION

The combination of risperidone with mood stabilizers was an effective and safe treatment for manic symptoms and coexisting depressive symptoms of bipolar disorder.

Current issues: women and bipolar disorder

While the treatment of bipolar disorder (BD) is typically complex, the treatment of women with bipolar disorder is even more challenging because clinicians must also individualize treatment based on the potential for pregnancy, drug interactions with oral contraceptives, and an increased risk of endocrine diseases that can either impact the course of illness or become manifest with some treatments. Women with BD should be checked for hypothyroidism, and if prescribed antidepressants, carefully watched for rapid cycling or a mood switch to mania, hypomania, or a mixed state. Several medications interact with oral contraceptives or increase the risk of developing polycystic ovary syndrome. Consideration of possible pregnancy is essential, and should be planned in advance whenever possible. Rates of recurrence have been shown to be equal in pregnant and nonpregnant women with BD. Risks of medication to the fetus at various points of development must be balanced against the risks of not treating, which is also detrimental to both fetus and mother. The postpartum period is a time of especially high risk; as many as 40% to 67% of women with BD report experiencing a postpartum mania or depression. The decision to breastfeed must also take into account the adverse impact of sleep deprivation in triggering mood episodes. In order to best address these issues, clinicians must be familiar with the data and collaborate with the patient to assess risks and benefits for the individual women and her family.

Hypomania: a depressive inhibition override defense mechanism

OBJECTIVE

Evolutionary perspectives on bipolar disorders can further our understanding of the origins of these conditions, and assist clinicians in distinguishing normal from abnormal states. Hypomania is unique amongst bipolar conditions in that it seems to have beneficial aspects and can be difficult to diagnose, in contrast to full-blown mania and depression. A theoretical perspective regarding the evolution of hypomania as a defense mechanism is presented.

METHOD

Literature review focused on the fitness reducing aspects of depression and the fitness enhancing aspects of hypomania/mania.

RESULTS

Of all the adversity inherent in depression, inhibition of physical and mental activity-depressive inhibition-has the most detrimental consequences, and throughout our evolution would have significantly reduced fitness. It is proposed that hypomania evolved as a depressive inhibition override defense mechanism, typically operating in a short-term time frame, to restore physical and mental activity to fitness sustaining or enhancing levels. Over-activity and not mood enhancement enabled hypomania to function as a defense mechanism against the fitness reducing state of depressive inhibition. Contributing to depressive inhibition are the Behavioral Activation System (BAS) and the Behavioral Inhibition System (BIS), two basic motivational systems. Depressive inhibition consists to some extent of low BAS and high BIS. As human intelligence evolved cognitions inhibiting BAS and activating BIS became amplified, resulting in intensified depressive inhibition.

LIMITATIONS

A theoretical perspective.

CONCLUSIONS

Given its ability to override depressive inhibition hypomania might be viewed as a natural treatment as opposed to a problem to treat, producing maximal improvement in areas where functioning has suffered the most while typically enhancing social behavior.

Epidemiology, diagnosis and management of mixed mania

The presence of depressive symptomatology during acute mania has been termed mixed mania, dysphoric mania, depressive mania or mixed bipolar disorder. Highly prevalent, mixed mania occurs in at least 30% of bipolar patients. Correct diagnosis is a major challenge. The DSM diagnostic criteria, the most widely adopted clinical convention, require a complete manic and complete depressive syndrome co-occurring for at least 1 week. However, recent alternative categorical and dimensional studies of manic phenomenology have shown that there are certain depressive symptoms or constellations that have special clinical importance when describing mixed states, such as depressed mood and anxiety symptomatology that do not overlap with manic symptoms. Patients with mixed mania are over-represented in the subgroup with severe and treatment-resistant symptoms. The course and prognosis of mixed mania are worse than that of pure manic forms in the medium and long term, with higher recurrence rates, higher frequency of co-morbid substance abuse and greater risk of suicidal ideation and attempts. Moreover, mixed manic episodes are usually associated with increased depression during follow-up, greater risk of rapid cycling course and higher prevalence of physical co-morbidities, principally related to thyroid function. All these factors are very relevant to selection of treatment. There are three crucial steps in the treatment of mixed mania--making the correct diagnosis, starting treatment early, and considering not only the acute state but also maintenance treatment and the patient's long-term outcome. Although challenging, acute mixed episodes are treatable. To date there have been no controlled studies devoted exclusively to treatment of mixed mania, and the only controlled data available therefore derive from sub-analyses of randomised clinical trials. Both short-term and maintenance treatments of patients with mixed mania require experience and usually involve the combination of different treatments. As a general rule, there is some consensus about discontinuing antidepressants during mixed mania. Olanzapine, aripiprazole or valproate semisodium (divalproex sodium) are first-line drugs for mild episodes; severe episodes of mixed mania usually require treatment with a combination of valproate semisodium or lithium plus an antipsychotic, preferably an atypical agent. Carbamazepine is also useful for the treatment of mixed mania. High-dose medications are sometimes needed to control the episode, and time to remission is usually longer than in pure mania. Importantly, patients with mixed manic episodes have more adverse events of psychopharmacological treatment. In some cases, electroconvulsive therapy is required.

A clinical study comparing manic and mixed episodes in patients with bipolar disorder

OBJECTIVE: Mixed episodes have been described as more severe than manic episodes, especially due to their longer duration and their association with higher rates of suicide attempts, hospitalization and psychotic symptoms. The purpose of this study was to compare the severity between mixed and pure manic episodes according to DSM-IV criteria, through the evaluation of sociodemographic data and clinical characteristics. METHOD: Twenty-nine bipolar I patients presenting acute mixed episodes were compared to 20 bipolar I patients with acute manic episodes according to DSM-IV criteria. We analyzed (cross-sectionally) episode length, presence of psychotic symptoms, frequency of suicide attempts and hospitalization, Young Mania Rating Scale scores, Hamilton Depression Rating Scale scores and the Clinical Global Assessment Scale scores. RESULTS: Young Mania Rating Scale scores were higher in manic episodes than in mixed episodes. There were no differences in gender frequency, CGI scores and rates of hospitalization, suicide attempts and psychotic symptoms, when mixed and manic episodes where compared. Patients with mixed episodes were younger. CONCLUSION: In our sample, mixed states occurred at an earlier age than manic episodes. Contrary to previous reports, we did not find significant differences between manic and mixed episodes regarding severity of symptomatology, except for manic symptoms ratings, which were higher in acute manic patients. In part, this may be explained by the different criteria adopted on previous studies.

Pharmacotherapy of bipolar mixed states

OBJECTIVE

Mixed episodes comprise up to 40% of acute bipolar admissions. They are difficult-to-treat, complex clinical pictures. This review provides an overview of the available literature on the pharmacotherapy of manic-depressive mixed states and suggests treatment options.

METHOD

Literature was identified by searches in Medline, Embase and the Cochrane Controlled Trials Register. Studies were considered relevant if they contained the keywords mixed mania, mixed state(s), mixed episode(s), treatment, therapy, study or trial.

RESULTS

Overall, there were very few double-blind, placebo-controlled studies specifically designed to treat manic-depressive mixed states. Rather, patients with mixed states comprised a sub-group of the examined patient cohorts. Nevertheless, the data show that acute mixed states do not respond favourably to lithium. Instead, valproate and olanzapine are drugs of first choice. Carbamazepine may play a role in the prevention of mixed states. Antidepressants should be avoided, because they may worsen intraepisodic mood lability. Lamotrigine may be useful in treating mixed states with predominantly depressive symptoms.

CONCLUSIONS

More treatment studies specifically designed to treat the complex clinical picture of mixed states are clearly needed. Current treatment recommendations for clinical practice based on the available literature can only target select aspects of these episodes.

Efficacy of atypical antipsychotics in bipolar disorder

Bipolar disorder is a severe and recurrent disorder. Atypical antipsychotics have emerged as both an alternative and adjunct to conventional mood stabilisers. The manic phase of the illness is the best studied, and it appears that a class effect with regards to efficacy is present in both monotherapy and augmentation studies. Evidence for efficacy of atypical antipsychotics in depression is emerging. At this stage controlled data are available for both olanzapine and quetiapine. Maintenance data demonstrating efficacy are available for olanzapine. Atypical antipsychotics have utility in treating acute agitation and aggression in manic episodes of bipolar disorder. Subgroup analyses from trials treating manic phase bipolar disorder, and an open-label study of rapid cycling, have suggested that atypical antipsychotics may be useful for the treatment of mixed states and rapid cycling. Several studies have suggested that atypical antipsychotics may be useful in treatment-refractory episodes of bipolar disorder. The current available data suggest greater efficacy of the atypical antipsychotics in mania than in depression, although the data are fairly clear that induction of depression is not an issue with the atypical antipsychotics. A number of trials are underway that will hopefully address many of the questions still pending.

'Bipolar missed states': the diagnosis and clinical salience of bipolar mixed states

OBJECTIVE

To explore diagnostic and treatment issues concerning bipolar mixed states.

METHOD

Bipolar mixed states are described and concerns about diagnostic and treatment difficulties are summarized and discussed.

RESULT

Mixed states can present with equal admixtures of depressive or manic symptoms, or more commonly one component predominates. There is fair consensus, although little data, regarding the management of manic mixed states. However depressive mixed states are far more complex both in terms of recognition and management. People suffering from mixed states characteristically present with complaints of depression.

CONCLUSIONS

The boundaries between depressive mixed states and agitated depression are vague, yet carry substantial therapeutic implications. Bipolar mixed states are often difficult to treat, and tend to take much longer to settle than either pure mania or depression. Furthermore there is data that treatment with antidepressants can worsen the course of mixed states. Hence missed diagnoses can potentially have negative clinical implications. Therefore in this paper the clinical presentation, diagnosis and therapy of mixed states is reviewed with a view to improving management.

[Diagnosis and treatment of mixed states]

Mixed States are described in the literature using based on different definitions resulting in different descriptions of the clinical and demographic characteristics, of these episodes, but although they are always asdeemed a severe form of Bipolar disorder with worse prognosis and more prevalent than previously described. The aim of this article is to present a review of these different definitions and their impact on the study of mixed states. Pharmacological treatment is also discussed.

Cross-sectional similarities and differences between schizophrenia, schizoaffective disorder and mania or mixed mania with mood-incongruent psychotic features

BACKGROUND

The cross-sectional clinical differentiation of schizophrenia or schizoaffective disorder from mood-incongruent psychotic mania or mixed mania is difficult, since pathognomonic symptoms are lacking in these conditions.

AIMS OF THE STUDY

To compare a series of clinical variables related to mood and cognition in patient groups with DSM-III-R diagnosis of schizophrenia, schizoaffective disorder, mood-incongruent psychotic mania and mood-incongruent psychotic mixed mania.

METHODS

One hundred and fifty-one consecutive patients were evaluated in the week prior to discharge by using the structured clinical interview for DSM-III-R-patient edition (SCID-P). Severity of psychopathology was assessed by the 18-item version of the brief psychiatric rating scale (BPRS) and negative symptoms by the scale for assessment of negative symptoms (SANS). Level of insight was assessed with the scale to assess unawareness of mental disorders (SUMD).

RESULTS

There were no differences in rates of specific types of delusions and hallucinations between subjects with schizophrenia, schizoaffective disorder, psychotic mania and psychotic mixed mania. SANS factors scores were significantly higher in patients with schizophrenia than in the bipolar groups. Patients with mixed state scored significantly higher on depression and excitement compared to schizophrenia group and, to a lesser extent, to schizoaffective group. Subjects with schizophrenia showed highest scores on the SUMD indicating that they were much more compromised on the insight dimension than subjects with psychotic mania or mixed mania.

CONCLUSION

Negative rather than affective symptomatology may be a useful construct to differentiate between schizophrenia or schizoaffective disorders from mood-incongruent psychotic mania or mixed mania.

Special considerations in treating bipolar disorder in women

There are obvious gaps in research surrounding issues specific to women who suffer from bipolar disorder, including gender differences and their implications for management, the impact of the reproductive cycle, and evidence based treatment guidelines for pregnancy and the postpartum period. Gender differences have not been reported for the prevalence of bipolar disorder; however, women are more likely to experience rapid cycling, mixed mania, and antidepressant-induced manias. This may affect response to treatment, which has been found, in some cases, to differ in men and women. In addition, side effects in response to treatments may well differ in men and women, especially with regard to lithium and valproate prescription. The course of bipolar disorder in women may be influenced by the menstrual cycle, pregnancy, the postpartum period, and menopause, although many issues require further clarification. Treatment of bipolar disorder during pregnancy and the postmenopausal period requires careful consideration, as does treatment during the childbearing years, as some mood stabilizers influence the metabolism of oral contraceptives. This review article has attempted to evaluate existing literature regarding women with bipolar disorder in a comprehensive and critical way, and to consolidate into a single source the gender-specific aspects of the disorder that may have treatment implications for women.

Outcome of schizophreniform disorder

The aim of this review is to find data about the outcome of schizophreniform disorder. As different definitions of schizophreniform disorder were found in the literature, it was not surprising that data on its outcome, and on the relationship of schizophreniform disorder to schizophrenia and to mood disorders (as this relationship is linked to outcome), were often different and opposite. Its classic description of an acute onset psychotic episode with mood instability and a relatively brief duration should be the focus of future studies. Current studies, apart from a small number, lump together different (and probably distinct) subtypes of schizophreniform disorder (one with good prognostic features, and one without good prognostic features, according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition). Studies of mixed samples led to different results, probably depending on the relative prevalence of one subtype over the other one. The few studies on schizophreniform disorder with good prognostic features found more often an episodic, recurrent course, and a family history of mood disorders. These features link this schizophreniform disorder subtype more to mood disorders than to schizophrenia. If confirmed by future studies, these preliminary findings can have very important treatment implications, given the very different treatment strategies in mood disorders compared with schizophrenia.

Is there a link between atypical and early-onset "unipolar" depression and bipolar II disorder?

The aim of the present study was to determine whether there is a link between "unipolar" depression with atypical features and early onset, and bipolar II disorder, using atypical features and early onset as markers of bipolarity. A total of 158 consecutive unipolar and 234 bipolar II major depressive episode (MDE) outpatients were interviewed using the Structured Clinical Interview for DSM-IV (SCID). Patients were divided into those with and without atypical features, and into those with and without early onset. Comparisons were made on variables reported to distinguish bipolar from unipolar: age of onset, recurrences, atypical features, depressive mixed state (MDE plus three or more concurrent hypomanic symptoms [DMX3]), and bipolar II family history. Compared to bipolar II patients, patients with atypical unipolar were not significantly different regarding age of onset, DMX3, recurrences, and bipolar II family history. Compared to non-atypical unipolar patients, atypical unipolar patients had a significantly different age of onset. Nonatypical unipolar patients, versus bipolar II patients, were significantly different regarding age of onset, recurrences, DMX3, and bipolar II family history. Early onset unipolar, versus bipolar II, were not significantly different regarding atypical features, recurrences, DMX3, and bipolar II family history. Later onset unipolar patients, versus bipolar II patients, were significantly different regarding atypical features, recurrences, DMX3, and bipolar II family history. These results support a link of atypical and early-onset "unipolar" depression with bipolar II disorder, and support Pages and Dunner's suggestion to combine bipolar II and recurrent unipolar into a single group.

Family history validation of the bipolar nature of depressive mixed states

BACKGROUND

Recent data indicate that depressive mixed states (DMX), major depressive episode (MDE) plus few concurrent hypomanic symptoms are common in clinical practice but omitted in DSM-IV. Our aims were to find the sensitivity and specificity of DMX for the diagnosis of bipolar II disorder, and validate it against familial bipolarity.

METHODS

377 consecutive private outpatients presenting with psychoactive drug-free MDE were interviewed with the Structured Clinical Interview for DSM-IV (Clinician Version). History of past hypomanic episodes and presence of hypomanic symptoms during the index MDE were systematically recorded. Of these, 226 were bipolar II and 151 unipolar. DMX3 was defined as an MDE plus three or more intra-episodic hypomanic symptoms.

RESULTS

DMX3 was present in 58.4% of bipolar II, and 23.1% of unipolar patients. It was significantly associated with variables distinguishing bipolar from strictly defined unipolar disorders (younger age at onset, more MDE recurrence, more atypical features, more bipolar II family history). Unipolar DMX3 (MDE with documented hypomania solely intra-episodically) was not significantly different from bipolar II MDE on age at onset, atypical features, and bipolar II family history.

CONCLUSIONS

Results support the inclusion of DMX3 (bipolar II and 'unipolar') into the bipolar spectrum. Adding the 23% of the UP-DMX3 to the roster of less-than-manic outpatient depressives will boost the rate of bipolarity in this outpatient depressive population to a respectable 70%, the highest rate yet reported for the bipolar spectrum below the threshold of mania.

Depressive mixed state frequency: age/gender effects

Depressive mixed state (DMX), a major depressive episode (MDE) combined with few manic/hypomanic symptoms, is understudied. Age and gender are important variables in mood disorders. The aim of the present study was to determine whether age and gender had any effect on the frequency of DMX. Consecutive unipolar (n = 144) and bipolar II (n = 218) drug-free MDE out-patients were interviewed with the Structured Clinical Interview for DSM-IV when presenting for MDE treatment. The presence of hypomanic symptoms during the index MDE was assessed systematically. Depressive mixed state was defined as a MDE with three or more concurrent hypomanic symptoms (DMX3), following previous reports. Associations were tested by logistic regression. The results showed that the DMX3 frequency was 43.9% and that it affected more females than males. Frequency decreased with age. The lower frequency with age was related to the lower frequency of bipolar II disorder with age. Bipolar disorder family history of DMX3 patients did not change with age. In conclusion, the frequency of DMX3 was high and related to age. The high frequency of DMX3 supports the clinical usefulness of the definition, as well as observations that antidepressants may worsen its hypomanic symptoms, whereas antipsychotics and mood stabilisers may treat them. A bipolar vulnerability seems to be required for the appearance of DMX3 also in later life.

Rapid cycling bipolar disease: new concepts and treatments

Having been recognized by Kraeplin at the beginning of the 20th century, rapid cycling was first described as a specific entity by Dunner et al. in 1974. The prevalence of rapid cycling ranges from 12% to 20% in patients with bipolar disorder who are not selected for a high rate of cycling.

Depressive mixed state: testing different definitions

The aim of this study was to test different definitions of depressive mixed state (DMX) (major depressive episode (MDE) with some concurrent hypomanic symptoms), to find which one could better define DMX. Unipolar and bipolar II MDE outpatients (n = 168) were interviewed with the DSM-IV Structured Clinical Interview. Depressive mixed state was defined as a MDE with two or more (DMX2), and as a MDE with three or more (DMX3) concurrent hypomanic symptoms. DMX2 was present in 71.8% bipolar II patients, and in 41.5% unipolar (P < 0.01). DMX3 was present in 46.6% of bipolar II, and in 7.6% unipolar patients (P < 0.01). DMX2 and DMX3 had almost the same significant and non-significant associations with study variables (diagnosis, gender, age, age at onset, illness duration, MDE recurrences, axis I comorbidity, MDE severity, depression chronicity, hypomanic, MDE, psychotic, melancholic, and atypical symptoms and features). DMX3 was more strongly associated with bipolar II than DMX2 (odds ratio 10.4 vs 3.5). Findings suggest that DMX3 may be a better definition of DMX due to its stronger association with bipolar II disorder. Findings have important clinical and treatment implications because antidepressants may worsen DMX, and the presence of DMX may induce clinicians to assess systematically and carefully the history of past hypomania.

A theoretical reappraisal of mixed states: dysphoria as a third dimension

Mixed states are heterogeneous clinical entities difficult to define precisely. The stringent actual DSM IV criteria are unsatisfactory for current clinical use. Many frequently encountered mixed patients benefit without an accurate diagnosis from biological therapeutic interventions such as the introduction of mood stabilizers. We propose a brief review of the definition and characteristics of mixed states and propose a new approach to the typology of mixed states. Based on recent literature data, we add to the depressive and manic syndrome the concept of dysphoria as a third dimension. Integrating this three dimensional approach with recent factor analysis, we describe in addition to the DSM IV mixed state (type I) two new subtypes of mixed states (type IIM and IID). This new typology can give the clinician a more accurate understanding of the complex and polymorphous reality of mixed states and help him make more specific therapeutic interventions. These subtypes of mixed states will need validation through prospective clinical studies. Biological differences, differential outcome over time, and differential response to treatment will be important validation criteria.