Bipolar Spectrum Disorder

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.

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