Tuesday, February 3, 2009

Mixed Bipolar Depression: You Really Need to Be Reading This

Four and a half years ago, I sat down with leading bipolar expert Ellen Frank PhD of the University of Pittsburgh. I asked her to talk about a study she had been involved in concerning mixed depressions, that is, depression with some features of mania.

"What we've been arguing about is that even isolated symptoms that don't cluster together to create episodes may be important," she told me.

Emil Kraepelin, the pioneering diagnostician who coined the term manic-depression, recognized back in the early twentieth century that depression and mania could combine together to produce no fewer than six mixed states. Yet the DSM recognizes only one - full-blown mania with full-blown depression. By this criteria, only those with bipolar I are recognized as having mixed states.

The DSM is due for revision in 2012, and clearly things need to change. This month's American Journal of Psychiatry features the latest findings to emerge from the NIMH-underwritten STEP-BD real world clinical trials on bipolar patients.

In the study, of 1,380 patients diagnosed with bipolar depression, 54 percent had co-occurring subthreshold (one to three) manic symptoms while another 15 percent had a full mixed episode (at least four manic symptoms). Significantly, 71 percent of the mixed population had a bipolar II diagnosis. Only one-third of the patients had "pure" bipolar depression - that is, depression with no mania symptoms.

More than two thirds of the mixed population showed marked or severe irritability (think road rage). The mixed group were also more prone to attempt suicide. Common manic symptoms included distractibility, racing thoughts, and psychomotor agitation. We are talking depression with unwanted add-ons, and, not surprisingly, these depressions are more difficult to treat.

An earlier series of STEP-BD studies found that adding an antidepressant to a mood stabilizer did not, as expected, induce more switches into mania in the "pure" depression group. But this changed for the "mixed" group. As the study authors pointed out, clinicians who fail to pick up mania symptoms in depression may mistakenly "assume a beneficial role for antidepressant psychopharmacology."

Leading researchers such as Hagop Akiskal MD of the University of California, San Diego have advanced strong cases that the "mixed" population is much larger than psychiatry recognizes. STEP-BD now provides overwhelming evidence in support of this proposition.

Mixed states also jump the artificial divide between bipolar and unipolar depression. Perhaps even more important than knowing whether you have unipolar depression or bipolar is knowing precisely how "mixed" your depressions (and manias and hypomanias) are.

Chances are your psychiatrist is operating on the assumption that your depression is just depression. Maybe, maybe not. The onus is on you to get a dialogue going. Now more than ever, "knowledge is necessity."

Further reading from mcmanweb:

Treating Bipolar Depression

When Nassir Ghaemi MD of Tufts University was in residency at McLean Hospital, he assumed there was no harm in using antidepressants to treat bipolar depression. After all, "depression was depression," or so he and just about every clinician thought.

The Mood Spectrum

So what do we do with these irritable and depressed people with or without mixed states that the DSM presently ignores?


cretin said...

I can attest to how bad and dangerous mixed states are. Fortunately for rapid-cycling me, they were short lived or else.... I've experienced them all my adult life, but didn't know that they were part of the bipolar illness until the last few years. That is two decades going through this madness before realizing its part of the illness. There is too much emphasis on pure mania and pure hypomania in the literature and on websites. There definitely needs to be better descriptions of both mixed mania and mixed hypomania available to patients. Your site is the only one I know of that does so. Thanks!

John McManamy said...

Many thanks, Cretin. I experience mixed states, myself, so I have strong incentive to write about them. Hope more writers will join the conversation. Please keep posting.

Anonymous said...

Dear John,

I can also attest to how Mixed depressive states are DANGEROUS. My story is quite remarkable. I suffered my first major depressive episode at 17 where I spent 9 months not leaving my bed and crying. I had a couple of moderate depressions in between 17 and 26 which lasted only two months.

Then in 2006 I started to rapid cycle and had a hypomanic state before I fell into a deep depression which later switched to a mixed state with severe major depression superimposed with mania or hypomania. I felt very flat (no pleasure or interest in anything or anyone) and very fatigued. I could not concentrate to the point that reading one paragraph a day was an achievement. Yet at the same time I experienced horrible racing thoughts which I could not stop and was very talkative, I was very restless and agitated and the only thing I was occupied with was death and suicidal thoughts.

In sept 07 I had my first attempt at taking my life and found myself on life support.

I was misdiagnosed as borderline personality disorder/ or traits and discharged to my gp.

I had 6 more attempts all resulting in ICU admission ventilated and intubated.

I was not believed that I was depressed by the same hospital because there was no signs of major depression (of course there wasn't when I was both high and down at the same time and I am sitting in ICU bragging to the toxicologist about my toxicology knowledge!).

I suffered greatly. During this time I went on a trial of 3 antidepressants which either did nothing or agravated my mixed state.

I was finally dx properly by two professors, one with bipolar I (mixed state) and another with bipolar II (mixed state). I was told to immediately cease anti-depressants and was put on 2 mood stablizers and I noticed the difference. For the first time, my mind felt at peace. Hoever, because of my delay in dx, I still suffer from the psyhological effects of my actions of my last year though.

I am truly a testamony that a correct dx between boderline pd/ unipolar depression and bipolar is so important and could save lifes and preven needless suffering.

John, is there such as a thing as mixed states in bipolar II or is that just in bipolar I (I don't think it matters though as the treatment is the same but just interested to know). I have been dx as both bipolar I and II with mixed states by two highly esteemed prof so wanted to know the difference.

If you have any questions about my experience (this is just a short version) please feel free to ask me, I have been there and done that!

John McManamy said...

Hi, Anonymous. Many thanks for posting this. I'd love to work with you further on this, because the issues you raise are absolutely critical to our recovery.

I've also written here and elsewhere about how the possibility of borderline further complicates the issue of getting the diagnosis right.

Is it depression? Is it depression that acts like bipolar? Is it bipolar? Is it borderline?

To answer your question: The DSM doesn't recognize mixed states in bipolar II, which is patently wrong. Hopefully, the next edition will correct this. Clearly, as the STEP-BD study I cited above makes clear, there's a lot of bipolar II mixed states going around.

Back to you - your story and insights are very important. People will greatly benefit from learning more about what you went through - so let's talk.

You can contact me via my website. Click the mcman link at the top right, and from my website click the "contact" link at the bottom.

Talk to you soon -