Diurnal variation in the direction of mood switches in patients with rapid-cycling bipolar disorder

Evidence of weekly cyclicity in mood and functional impairment in those with a bipolar disorder

A key characteristic of bipolar disorder is fluctuation in mood symptoms and functional capacity, yet assessment of bipolar symptomatology often relies heavily on interval measurement that is unable to capture the full range of daily symptom variability and severity. The current study provides a detailed analysis of the variability in mood symptoms, functional impairment and medication compliance in a large sample of individuals newly diagnosed with bipolar disorder. Individuals diagnosed with bipolar disorder in the previous 12 months (n=192) rated their mood, functional impairment, medication compliance and symptom triggers daily over 10 consecutive weeks. High mood, low mood and functional impairment were found to vary on a weekly cycle, independently of medication compliance. Low mood and functional impairment were worse on weekdays, particularly Mondays and Tuesdays, whereas mood was most elevated on Saturdays. Work-related stressors were the most common symptom triggers on weekdays, whereas sleep-related problems and positive social events were the most common triggers on weekends. This study provides evidence that individuals newly diagnosed with bipolar disorder experience fluctuations in mood and functioning that vary according to a weekly cycle. This finding has implications for the assessment and treatment of patients, and for future research.

Diurnal and twenty-four hour patterning of human diseases: acute and chronic common and uncommon medical conditions

The symptom intensity and mortality of human diseases, conditions, and syndromes exhibit diurnal or 24 h patterning, e.g., skin: atopic dermatitis, urticaria, psoriasis, and palmar hyperhidrosis; gastrointestinal: esophageal reflux, peptic ulcer (including perforation and hemorrhage), cyclic vomiting syndrome, biliary colic, hepatic variceal hemorrhage, and proctalgia fugax; infection: susceptibility, fever, and mortality; neural: frontal, parietal, temporal, and occipital lobe seizures, Parkinson's and Alzheimer's disease, hereditary progressive dystonia, and pain (cancer, post-surgical, diabetic neuropathic and foot ulcer, tooth caries, burning mouth and temporomandibular syndromes, fibromyalgia, sciatica, intervertebral vacuum phenomenon, multiple sclerosis muscle spasm, and migraine, tension, cluster, hypnic, and paroxysmal hemicranial headache); renal: colic and nocturnal enuresis and polyuria; ocular: bulbar conjunctival redness, keratoconjunctivitis sicca, intraocular pressure and anterior ischemic optic neuropathy, and recurrent corneal erosion syndrome; psychiatric/behavioral: major and seasonal affective depressive disorders, bipolar disorder, parasuicide and suicide, dementia-associated agitation, and addictive alcohol, tobacco, and heroin cravings and withdrawal phenomena; plus autoimmune and musculoskeletal: rheumatoid arthritis, osteoarthritis, axial spondylarthritis, gout, Sjögren's syndrome, and systemic lupus erythematosus. Knowledge of these and other 24 h patterns of human pathophysiology informs research of their underlying circadian and other endogenous mechanisms, external temporal triggers, and more effective patient care entailing clinical chronopreventive and chronotherapeutic strategies.

Manipulating the sleep-wake cycle and circadian rhythms to improve clinical management of major depression

BACKGROUND

Clinical psychiatry has always been limited by the lack of objective tests to substantiate diagnoses and a lack of specific treatments that target underlying pathophysiology. One area in which these twin failures has been most frustrating is major depression. Due to very considerable progress in the basic and clinical neurosciences of sleep-wake cycles and underlying circadian systems this situation is now rapidly changing.

DISCUSSION

The development of specific behavioral or pharmacological strategies that target these basic regulatory systems is driving renewed clinical interest. Here, we explore the extent to which objective tests of sleep-wake cycles and circadian function - namely, those that measure timing or synchrony of circadian-dependent physiology as well as daytime activity and nighttime sleep patterns - can be used to identify a sub-class of patients with major depression who have disturbed circadian profiles.

SUMMARY

Once this unique pathophysiology is characterized, a highly personalized treatment plan can be proposed and monitored. New treatments will now be designed and old treatments re-evaluated on the basis of their effects on objective measures of sleep-wake cycles, circadian rhythms and related metabolic systems.

The vigilance regulation model of affective disorders and ADHD

According to the recently proposed vigilance model of affective disorders (vigilance in the sense of "brain arousal"), manic behaviour is partly interpreted as an autoregulatory attempt to stabilise vigilance by creating a stimulating environment, and the sensation avoidance and withdrawal in Major Depressive Disorder (MDD) is seen as an autoregulatory reaction to tonically increased vigilance. Indeed, using a newly developed EEG-based algorithm, hyperstable vigilance was found in MDD, and the contrary, with rapid drops to sleep stages, in mania. Furthermore, destabilising vigilance (e.g. by sleep deprivation) triggers (hypo)mania and improves depression, whereas stabilising vigilance, e.g. by prolonged sleep, improves mania. ADHD and mania have common symptoms, and the unstable vigilance might be a common pathophysiology. There is even evidence that psychostimulants might ameliorate both ADHD and mania. Hyperactivity of the noradrenergic system could explain both the high vigilance level in MDD and, as recently argued, anhedonia and behavioural inhibition. Interestingly, antidepressants and electroconvulsions decrease the firing rate of neurons in the noradrenergic locus coeruleus, whereas many antimanic drugs have opposite effects.

Hyperstable regulation of vigilance in patients with major depressive disorder

OBJECTIVES

This study tested the hypothesis that patients with depression show less and later declines into lower EEG vigilance stages (different global functional brain states) under resting conditions than healthy controls, as proposed by the vigilance theory of affective disorders.

METHODS

Thirty patients with Major Depressive Disorder (19 female; mean age: 37.2 years, SD: 12.6) without psychotropic medication and 30 carefully age- and sex-matched controls (19 female; mean age: 37.3 years, SD: 12.8) without past or present mental disorders underwent a 15-min resting EEG. EEG-vigilance regulation was determined with a computer-based vigilance classification algorithm (VIGALL, Vigilance Algorithm Leipzig), allowing a classification of vigilance stages A (with substages A1, A2 and A3), B (with substages B1 and B2/3) and C.

RESULTS

Depressive patients spent significantly more time in the highest EEG vigilance substage A1, and less time in substages A2, A3 and B2/3 than controls. In depressive patients, a significantly longer latency until the occurrence of substages A2, A3 and B2/3 was observed. No significant group differences in the percentage of B1 segments or the latency until occurrence of B1 were found.

CONCLUSIONS

The results confirm the hypothesis that patients with depression show less (and later) declines into lower EEG vigilance stages under resting conditions than healthy controls, and support the vigilance theory of affective disorders linking a hyperstable vigilance regulation to depression.

P2RX7: expression responds to sleep deprivation and associates with rapid cycling in bipolar disorder type 1

Context

Rapid cycling is a severe form of bipolar disorder with an increased rate of episodes that is particularly treatment-responsive to chronotherapy and stable sleep-wake cycles. We hypothesized that the P2RX7 gene would be affected by sleep deprivation and be implicated in rapid cycling.

Objectives

To assess whether P2RX7 expression is affected by total sleep deprivation and if variation in P2RX7 is associated with rapid cycling in bipolar patients.

Design

Gene expression analysis in peripheral blood mononuclear cells (PBMCs) from healthy volunteers and case-case and case-control SNP/haplotype association analyses in patients.

Participants

Healthy volunteers at the sleep research center, University of California, Irvine Medical Center (UCIMC), USA (n = 8) and Swedish outpatients recruited from specialized psychiatric clinics for bipolar disorder, diagnosed with bipolar disorder type 1 (n = 569; rapid cycling: n = 121) and anonymous blood donor controls (n = 1,044).

Results

P2RX7 RNA levels were significantly increased during sleep deprivation in PBMCs from healthy volunteers (p = 2.3*10⁻⁹). The P2RX7 rs2230912 _A allele was more common (OR = 2.2, p = 0.002) and the ACGTTT haplotype in P2RX7 (rs1718119 to rs1621388) containing the protective rs2230912_G allele (OR = 0.45–0.49, p = 0.003–0.005) was less common, among rapid cycling cases compared to non-rapid cycling bipolar patients and blood donor controls.

Conclusions

Sleep deprivation increased P2RX7 expression in healthy persons and the putatively low-activity P2RX7 rs2230912 allele A variant was associated with rapid cycling in bipolar disorder. This supports earlier findings of P2RX7 associations to affective disorder and is in agreement with that particularly rapid cycling patients have a more vulnerable diurnal system.

Time of mood switches in ultra-rapid cycling disorder: a brief review

The aim of this review is to assess the typical time of day that mood switches occur in ultra-rapid cycling disorder. It shall be determined, whether switches into depression or (hypo)mania are likelier to occur at particular times of the day or night, and whether a pattern of mood switch times can be discerned for different cycle lengths. Case reports giving information about cycle lengths and the times of day when switches have occurred were systematically compiled (sources: Medline and Web of Science). Cases with ultra-rapid (cycle lengths of days to weeks, including 48-h cycling) or ultra-ultra-rapid cycling (cycle lengths up to 24 h) were included (35 publications with 42 case reports). In cases with cycle lengths of days to weeks (n=11), switches appeared to occur at any time of the day. Patients with regular 48-h cycling (n=28) switched to depression or mania most often during nighttime hours. In all three patients with cycle lengths up to 24 h (ultra-ultra-rapid cycling), switches into depression occurred at night and switches into mania occurred at daytime. These findings indicate that in patients with mood cycles of 48h or less the switch process is closely linked to circadian aspects.

Sleep functioning in relation to mood, function, and quality of life at entry to the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD)

BACKGROUND

Sleep disturbance in bipolar disorder can be both a risk factor and symptom of mood episodes. However, the associations among sleep and clinical characteristics, function, and quality of life in bipolar disorder have not been fully investigated.

METHODS

The prevalence of sleep disturbance, duration, and variability, as well as their associations with mood, function, and quality of life, was determined from 2024 bipolar patients enrolled in the National Institute of Mental Health Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD).

RESULTS

Analyses indicated that 32% of patients were classified as short sleepers, 38% normal sleepers, and 23% long sleepers. Overall, short sleepers demonstrated greater mood elevation, earlier age at onset, and longer illness duration compared to both normal and long sleepers. Both short and long sleepers had greater depressive symptoms, poorer life functioning, and quality of life compared to normal sleepers.

DISCUSSION

Short sleep duration in bipolar disorder was associated with a more severe symptom presentation, whereas both short and long sleep duration are associated with poorer function and quality of life compared to normal sleep duration. Sleep disturbance could be a trait marker of bipolar disorder, though longitudinal assessments are warranted to assess potential causal relations and the longer-term implications of sleep disturbance in bipolar disorder.

Diurnal variation of depressive symptoms

Diurnal variation of depressive symptoms appears to be part of the core of depression. Yet longitudinal investigation of an individual's pattern regularity, relation to clinical state, and clinical improvement reveals little homogeneity. Morning lows, afternoon slump, evening worsening - all can occur during a single depressive episode. Mood variability, or the propensity to produce mood swings, appears to be the characteristic that most predicts capacity to respond to treatment. Laboratory studies have revealed that mood, like physiological variables such as core body temperature, is regulated by a circadian clock interacting with the sleep homeostat. Many depressed patients, particularly bipolar patients, show delayed sleep phase (late chronotype). Even small shifts in the timing and duration of sleep affect mood state (sleep deprivation and sleep phase advance have an antidepressant effect). The implications for treatment are to stabilize mood state by enhancing synchronization of the sleep-wake cycle with the biological clock (eg, with light therapy).

Clock genes may influence bipolar disorder susceptibility and dysfunctional circadian rhythm

Several previous studies suggest that dysfunction of circadian rhythms may increase susceptibility to bipolar disorder (BP). We conducted an association study of five circadian genes (CRY2, PER1-3, and TIMELESS) in a family collection of 36 trios and 79 quads (Sample I), and 10 circadian genes (ARNTL, ARNTL2, BHLHB2, BHLHB3, CLOCK, CRY1, CSNK1D, CSNK1E, DBP, and NR1D1) in an extended family collection of 70 trios and 237 quads (Sample II), which includes the same 114 families but not necessarily the same individuals as Sample I. In Sample II, the Sibling-Transmission Disequilibrium Test (sib-tdt) analysis showed nominally significant association of BP with three SNPs within or near the CLOCK gene (rs534654, P = 0.0097; rs6850524, P = 0.012; rs4340844, P = 0.015). In addition, SNPs in the ARNTL2, CLOCK, DBP, and TIMELESS genes and haplotypes in the ARNTL, CLOCK, CSNK1E, and TIMELESS genes showed suggestive evidence of association with several circadian phenotypes identified in BP patients. However, none of these associations reached gene-wide or experiment-wide significance after correction for multiple-testing. A multi-locus interaction between rs6442925 in the 5' upstream of BHLHB2, rs1534891 in CSNK1E, and rs534654 near the 3' end of the CLOCK gene, however, is significantly associated with BP (P = 0.00000172). It remains significant after correcting for multiple testing using the False Discovery Rate method. Our results indicate an interaction between three circadian genes in susceptibility to bipolar disorder.

The impairment of pediatric bipolar sleep: hypotheses regarding a core defect and phenotype-specific sleep disturbances

BACKGROUND

The nature of the sleep disturbances associated with different phenotypes of pediatric bipolar disorder is unknown. Most manic children exhibit delayed sleep onset, but only a minority display decreased need for sleep. The DSM-IV manic sleep criterion is inadequate.

METHOD

All published studies of the sleep characteristics of bipolar children and adolescents are reviewed. Relevant studies of pediatric unipolar depressed subjects, circadian variation of bipolar and sleep variables, and circadian neurobiology are also reviewed. This information forms the basis of hypotheses regarding the core defect of pediatric bipolar sleep and phenotype-specific sleep disturbances of bipolar children and adolescents.

LIMITATIONS

The extant research literature is extremely limited. Interpretation of bipolar sleep is confounded by day-to-day variation of bipolar symptoms and sleep parameters, the presence of comorbid conditions, and environmental and psychosocial factors.

CONCLUSIONS

The core defect of pediatric bipolar sleep is hypothesized to be a significant delay of the circadian sleep-wake cycle, a form of the delayed sleep-phase syndrome. Children and adolescents with part-day manic cycles and chronic mixed conditions typically will manifest delayed sleep onset, but not decreased need for sleep. Pediatric individuals with days-long manic cycles or chronic mania typically will manifest decreased need for sleep, produced by interaction between the sleep-onset phase delay and bedtime and early morning manic psychomotor acceleration. The sleep-onset phase delay, when expressed, is hypothesized to be a trait marker of bipolar spectrum illness. Revision of the DSM-IV manic sleep criterion is necessary.

The role of circadian clock genes in mental disorders

The study of molecular clock mechanisms in psychiatric disorders is gaining significant interest due to data suggesting that a misalignment between the endogenous circadian system and the sleep-wake cycle might contribute to the clinical status of patients suffering from a variety of psychiatric disorders. Sleep disturbances in major depressive disorder (MDD) are characterized by increased sleep latency, poorer sleep efficiency, reduced latency to the first rapid eye movement (REM) sleep episode, and early-morning awakening, but there is little data to indicate a role of circadian clock genes in MDD. There is also relatively little information regarding the role of clock genes in anxiety. In contrast, a significant amount of evidence gathered in bipolar disorder (BPD) patients suggests a circadian rhythm disorder, namely an advanced circadian rhythm and state-dependent alterations of REM sleep latency. Most research on the role of clock genes in BPD has focused on polymorphisms of CLOCK, but the lithium target GSK3 may also play a significant role. A circadian phase shift is also theorized to contribute to the pathophysiology of winter seasonal affective disorder (SAD). Certain allelic combinations of NPAS2, PER3, and BMAL1 appear to contribute to the risk of SAD. In chronic shizophrenia, disturbances of sleep including insomnia and reduced sleep efficiency have been observed. Genetic studies have found associations with CLOCK, PER1, PER3, and TIMELESS. Sleep and circadian changes associated with dementia due to Alzheimer's disease suggest a functional change in the circadian master clock, which is supported by postmortem studies of clock gene expression in the brain.

Diagnosis and classification of pediatric bipolar disorder

BACKGROUND

Many children and adolescents with apparent bipolar disorder cannot be meaningfully diagnosed using the DSM-IV. The variety of pediatric bipolar phenotypes observed in clinical practice remains unclarified.

METHOD

130 consecutively evaluated bipolar children and adolescents were assessed using semistructured clinical interviews and operational criteria that abandoned adherence to the DSM-IV cardinal symptom, duration of symptom persistence, and episodicity requirements.

RESULTS

97.6% of the total sample manifested either all three, or two of the three symptoms elation, grandiosity, and racing thoughts, when manic. 96.9% of the total sample exhibited five or more of the eight DSM-IV criterion symptoms when manic. 52.3% of the subjects manifested ultradian cycling; 22.3% manifested chronic mania or chronic simultaneous manic mixed conditions. Only 21.5% could be classified within the Leibenluft et al. [Leibenluft, E., Charney, D.S., Towbin, K.E., Bhangoo, R.K., Pine, D.S., 2003. Defining clinical phenotypes of juvenile mania. Am. J. Psychiatry 160, 430-437.] system. Problematic distractibility-inattention was present in 89.9% and recurrent rage attacks in 48.5% of the total sample. Older subjects exhibited significantly more depressive symptoms, and nonsignificantly greater prevalences of major depression, severe depression, and ultradian cycling than did younger subjects. The number of depressive symptoms was significantly correlated with ultradian cycling.

LIMITATIONS

This study relied upon retrospective as well as current reports of symptoms. The study results cannot be generalized to community samples.

CONCLUSIONS

We propose two testable hypotheses: (1) that the recurrent, or chronic, simultaneous presence of any two of the symptoms elation, grandiosity, and racing thoughts and a total of five DSM-IV manic symptoms (without specific cardinal symptom, duration, or episodicity requirements) will identify nearly all clinic-referred bipolar children and adolescents; and (2) that a comprehensive classification of pediatric bipolar phenotypes based upon pattern of manic symptom episodicity or chronicity and degree of depression will identify subtypes of pediatric bipolar disorder that have greater correspondence with treatment response than do those of the DSM-IV classification. Problematic distractibility-inattention and explosive irritability-rage are highly prevalent; their presences should be specified when indicated.

Effects of abstinence from habitual involvement in regular exercise on feeling states: an ecological momentary assessment study

Regular exercise was experimentally reduced to determine its effects on positive feeling states. Using ecological momentary assessments, 40 participants maintained their regular exercise routine on 3 days and were deprived of their scheduled exercise on 3 other days. They recorded their feeling states, using the Exercise-Induced Feeling Inventory, four times daily as well as prior to and following exercise. Multi-level modelling analyses controlling for diurnal variations in feeling states revealed that positive feeling states were elevated on days when exercise deprivation occurred compared with non-exercise days and when no deprivation manipulation occurred. People with lower exercise dependence symptoms felt better on days when they were deprived from exercise compared with non-exercise days, whereas people with higher exercise dependence symptoms felt about the same when they were deprived from exercise compared with non-exercise days. These findings demonstrate that positive feeling states occur following an acute bout of exercise and that exercise deprivation had a positive impact on feeling states, with the level of exercise dependence symptoms moderating this effect.

Actigraphic assessment of circadian activity and sleep patterns in bipolar disorder

OBJECTIVES

Theoretical accounts and psychological interventions for bipolar disorder indicate that disruption of circadian rhythms is important, both in affective episodes and as a vulnerability factor in subsyndromal periods. This study aims at assessing both circadian activity and sleep patterns using actigraphy within a bipolar sample experiencing low levels of subsyndromal symptoms. It is hypothesized that such participants will display circadian activity disruption in spite of low levels of symptoms.

METHODS

This study employed a mixed design with cross-sectional assessment of mood and week-long (7-day) recording of actigraphy data. All clinical participants were psychiatric outpatients within a UK NHS Hospital. Nineteen bipolar patients and 19 age- and gender-matched controls wore an actigraph for 7 days to obtain sleep and circadian activity data. SCID was used to confirm DSM-IV diagnostic status. Self-report measures of mood were obtained from both groups.

RESULTS

Bipolar patients were found to have less stable and more variable circadian activity patterns than controls. Regression analysis indicated that variability alone was a significant independent predictor of diagnostic group. There was evidence from raw activity data that bipolar patients were also less active than controls. These differences were not associated with levels of subsyndromal symptoms. Bipolar patients did not differ from controls on any of the sleep indices used.

CONCLUSIONS

Circadian activity disruption is apparent in bipolar patients even when not acutely ill. This finding is not associated with the presence of sleep disturbance. Should such patterns be replicated interventions to address both circadian instability and individual attributions for the effects of such instability are likely to be relevant to successful psychological interventions.

The contribution of daily experiences and acute exercise to fluctuations in daily feeling states among older, obese adults with knee osteoarthritis

This study examined the contribution of daily experiences and acute exercise to fluctuations in feeling states of older, obese adults with knee osteoarthritis and explored the role of perceived physical function and general health perceptions as moderator variables. Using an experience sampling procedure, a total of 964 feeling state assessments were recorded and coded into samplings that occurred either on a nonexercise day or prior to or following scheduled activity on an exercise day. Multilevel modeling analyses controlling for the influence of subjective stress, contemporaneous pain reports, and diurnal variations revealed that physical exhaustion was higher immediately following exercise. Analyses of the moderator variables demonstrated that general health perceptions and perceived physical function accounted for significant portions of between-subject variance with more positive perceptions of each variable being related to higher levels of pleasant feeling states and lower feelings of physical exhaustion. However, perceived physical function and general health perceptions did not influence feeling states that emerged in conjunction with physical activity. The present findings suggest that whereas daily fluctuations in feeling states are influenced by perceived physical function and general health perceptions, older adults with knee OA do not exhibit the improvements in feeling states that have often been observed following acute exercise in younger, more physically active populations.

Circadian rhythms, multilevel models of emotion and bipolar disorder--an initial step towards integration?

This paper sets out possible links between disruption of circadian rhythms in bipolar disorder and the affective symptom, which are experienced in this disorder. Evidence is drawn from Healy and Williams' [Psychiatr. Dev. 1 (1989) 49.] review of circadian function in manic depression, along with later reports, which indicate a role for disrupted circadian rhythms in both depressed and manic phases of manic depression (bipolar disorder). This is integrated within a version of the multilevel model of emotion proposed by Power and Dalgleish [Cognition and emotion: from order to disorder. Hove: Psychology Press (1997); Behav. Cognit. Psychother. 27 (1999) 129.]. The aim of this process is to propose a possible psychological mechanism by which the disruption of circadian rhythms might result in the observed clinical symptoms of bipolar disorder. The integration of these approaches leads to a number of specific testable hypotheses that are relevant to future research into the psychological treatment and understanding of bipolar disorder.

Contributions of acute bouts of vigorous physical activity to explaining diurnal variations in feeling states in active, middle-aged women

This study describes diurnal variations in feeling states in 84 women as a function of involvement in physical activity. Women completed feeling state checklists before and after bouts of vigorous physical activity that lasted a minimum of 20 min and on a stratified random-sampling protocol in response to a stimulus from an electronic pager. Participants self-reported the date, the time of day, the stimulus for responding, their current feeling states, and their ongoing activity. A total of 7,295 complete mood and activity reports were recorded in response to pager calls that were further coded into experience samplings that occurred on a nonexercise day, prior to exercise on an exercise day, and following exercise on an exercise day. Multilevel modeling analyses showed that in samplings recorded following exercise on exercise days, positive engagement, revitalization, and tranquility were elevated in comparison with predicted diurnal patterns.

Rapid-cycling bipolar disorder. An overview of research and clinical experience

Although many studies of RCBD have been reported over the last 2 decades, knowledge remains limited. Higher incidence in women is the sole clearly replicated finding in most studies. This finding might be mediated by cyclothymia, a temperament that is of higher prevalence in women and that might be considered as a normal variant of RC. Many questions remain unanswered. Review of putative risk factors, such as hypothyroidism and treatment with antidepressants, provides no conclusive answers. There is clinical evidence to implicate both factors. In principle, the thyroid connection can be approached rationally, yet there seems to be no relationship between thyroid status and response to thyroid augmentation. For this reason and given the potential risks of long-term thyroid use, this strategy should not be the first one to be tried in RC. Cumulatively, naturalistic studies over the past 30 years have strongly implicated antidepressants in switching and cycle acceleration, yet the double-blind, controlled, prospective studies that are needed to provide definitive answers are unlikely to be conducted for ethical reasons discussed in this article. Bipolar family history of RC probands appears indistinguishable from non-RC probands, indicating that most likely RCBD does not breed true. Although RC seems to be more lithium resistant with less likelihood of being symptom-free after 2 to 5 years of follow-up, many of these patients nonetheless have resolution of the RC course. There is no marked difference in suicide rates. An association of RC with bipolar type II, D-M-I pattern and those who switch into mania or hypomania on antidepressants is a provocative possibility: Antidepressants might introduce RC by first inducing a switch during a depressive episode, creating a D-M-I pattern, a pattern that is poorly responsive to lithium, which eventually degenerates into RC. Again, this sequence might be mediated by the high prevalence of cyclothymia in bipolar II patients. Thus, data from phenomenology, family history, and long-term outcome do not support RC as a separate entity. RC appears to be a temporary complicated phase in the illness, not a stable feature. This was noted by Kraepelin: I think I am convinced that that kind of classification must of necessity wreck on the irregularity of the disease. The kind and duration of the attacks and the intervals by no means remain the same in the individual case but may frequently change, so that the case must be reckoned always to new forms. Data by Gottschalk et al testify to the chaotic mood swings of contemporary bipolar disorder. Moreover RC is seen in other medical diseases, such as epilepsy, in which patients have phases of increase in frequency of episodes (seizures) that become refractory to treatment. Further longitudinal prospective studies are required to understand the complexity of this intriguing phenomenon and to provide better treatments. Algorithms deriving from tertiary research or university-based clinical experience may not generalize to RC or otherwise treatment-resistant bipolar patients seen in more routine practice. Illness severity in RCBD generally precludes double-blind controlled investigations. Meanwhile, clinicians may rely on discontinuing antidepressants, maintaining patients on combined mood stabilizers--of which valproate is probably the most useful--and making judicious use of atypical neuroleptics. Benzodiazepines and alcohol (which produce withdrawal), caffeine, stimulants, exposure to bright light, and sleep deprivation during excited phases should be avoided. Thyroid and nimodipine augmentation can be considered in those with the most malignant course. These are patients who need the maximal support that their psychiatrist can provide them. Office visits must be arranged as the last appointment of the day.