Bipolar Depression: Issues in Diagnosis and Treatment

Abstract

Although bipolar affective disorder is defined by the history of manic or hypomanic episodes, depression is arguably a more important facet of the illness. Depressive episodes, on average, are more numerous and last longer than manic or hypomanic episodes, and most suicides occur during these periods. Misdiagnosis of major depressive disorder delays initiation of appropriate therapy, further worsening prognosis. Distinguishing features of bipolar depression include earlier age of onset, a family history of bipolar disorder, presence of psychotic or reverse neurovegetative features, and antidepressant-induced switching. Bipolar I depressions should initially be treated with a mood stabilizer (carbamazapine, divalproex, lamotrigine, lithium, or an atypical antipsychotic); antidepressant monotherapy is contraindicated. More severe or "breakthrough" episodes often require a concomitant antidepressant, such as bupropion or a selective serotonin reuptake inhibitor (SSRI). The first treatment specifically approved for bipolar depression is a combination of the SSRI fluoxetine and the atypical antipsychotic olanzapine. For refractory depressive episodes, venlafaxine, the monoamine oxidase inhibitor tranylcypromine, and ECT are most widely recommended. The optimal duration of maintenance antidepressant therapy has not been established empirically and, until better evidence-based guidelines are established, should be determined on a case-by-case basis.

Circadian genes, rhythms and the biology of mood disorders

“…Thus antidepressants in the selective serotonin reuptake inhibitor (SSRI) class may also exert some of their effects on depression through modulation of the circadian clock. Interestingly, SSRIs and mood stabilizers can have opposing therapeutic actions in bipolar patients (Thase, 2005). This could be linked to their opposing actions on rhythms since SSRIs cause a phase advance in rhythms while lithium can cause a phase delay (Campbell et al, 1989;Sprouse et al, 2006).…”

Improving Treatment Adherence in Bipolar Disorder

“…Although this pernicious symptom course may be largely accounted for by the more limited armamentarium of effective treatments for bipolar depression (Thase, 2005), it is unclear to what extent it may also be accounted for by nonadherence to treatment. Indeed, there is reason to believe that certain depressotypic features adversely impact adherence behaviors, potentially contributing to the vicious cycle of depression that has emerged in bipolar disorder.…”

“…Yet the issue of treatment adherence may be particularly relevant to bipolar depression, as it currently dominates the long-term clinical course of the disorder (Judd et al, 2002;Miller et al, 2004), is associated with significant functional impairment (Calabrese, Hirschfeld, Frye, & Reed, 2004), and confers substantial risk for suicide (Tondo, Isacsson, & Baldessarini, 2003). Thus, if left untreated, bipolar depression is likely to be associated with significant morbidity and mortality.Although this pernicious symptom course may be largely accounted for by the more limited armamentarium of effective treatments for bipolar depression (Thase, 2005), it is unclear to what extent it may also be accounted for by nonadherence to treatment. Indeed, there is reason to believe that certain depressotypic features adversely impact adherence behaviors, potentially contributing to the vicious cycle of depression that has emerged in bipolar disorder.…”

What is culture? Culture is context-dependence!

“…Each of these latter symptoms reflects an increased focus on the self, the so-called ''increased self-focus'' in MDD (Thase 2005;Northoff 2007;Grimm et al 2009Grimm et al , 2011Alcaro et al 2010) and hence an abnormally ''reduced environmental focus''.…”