Five or more of the following marks a Depressive Disorder:
- Depressed mood—feeling low, sad or, as Shakespeare wrote, feeling life is dull, stale, flat and unprofitable.
- Loss of pleasure in usual activities.
- Weight or appetite changes.
- Change in sleep patterns.
- Psychomotor retardation—slow movements, halting speech, just dragging around.
- Fatigue, loss of energy.
- Feelings of worthlessness or guilt
- “Brain fog”—difficulty thinking, concentrating or forming thoughts, forgetfulness, trouble concentrating, indecisiveness, cloudy thinking.
- Suicidal impulses.
Two recent international studies involving over 8,000 patients are consistent with other estimates showing that almost 50% of depressed patients fall into the bipolar spectrum category. Bipolar Spectrum Disorder includes the following diagnostic categories:
- Bipolar I and Bipolar II Disorder characterized by mood swings alternating between normal mood, manic or hypomanic mood and depressed mood are found in 16% of depressed patients.
- Bipolar I patients have one or more manic episodes that are so severe that hospitalization is almost always required for treatment. Mania is marked by at least three of the following symptoms:
- Unrealistic, grandiose beliefs about one’s abilities or powers.
- Rapid speech that makes it difficult for others to keep up.
- Acting recklessly without thinking about the consequences.
- Racing thoughts, jumping quickly from one idea to the next.
- Distractibility marked by poor concentration and attention.
- Impulsiveness, poor judgment, agitation
- Sleeping very little but without loss of energy.
- Extreme irritability or euphoric mood.
- Bipolar II patients have three or more of the same symptoms, as those with Bipolar I Disorder but the symptoms are not as severe and don’t last as long. These symptoms are called hypomanic (hypo = below).
- A hypomanic episode is only required to persist for four days instead of seven as with a manic episode.
- Those in a hypomanic state can make bad decisions that harm relationships, careers and reputations, but they are able to perform without losing touch with reality, and they don’t require hospitalization.
- Antidepressant induced mania—depressed patients who become manic or hypomanic when taking an antidepressant.
- Depression with mixed features is characterized by at least three of the following symptoms:
- Elevated mood or a labile mood (rapid changes in mood).
- Uncomfortable elevated energy makes one feel wired, restless or gives a sensation of feeling like “I’m crawling out of my skin.”
- Impulsivity that often has a reckless tone such as quitting relationships or jobs, breaking things, aggressive driving or self-harm.
- Patients may attempt to relieve depression by over spending, binge eating, drug addiction or watching pornography.
- Unbearable anxiety—“Everything gets on my nerves. I’m tired and depressed in the day, then wired at night.”
- Increased confidence such as demanding or intimidating behavior, or absolute certainty of beliefs.
- Ruminating thoughts crowded with depressive or anxious feelings.
- Rapid speech associated with dramatic expressions of suffering.
Treatment of depression with mixed features:
- Antipsychotics for acute episodes such as aripiprazole (Abilify), risperidone (Risperdal) or lurasidone (Latuda). I prefer Abilify 5-15 mg daily because it is the most studied antipsychotic for this condition.
- For maintenance therapy lamotrigine (Lamictal) 50-200 mg daily or lithium to keep serum levels 0.4-0.6 mEq/L for depression; 0.8-1.2 mEq/L for mania.