Bipolar disorder major depressive episode

Amsterdam JD, Wang CH, Shwarz M, Shults J. Venlafaxine versus lithium monotherapy of rapid and non-rapid cycling patients with bipolar II major depressive episode a randomized, parallel group, open-label trial. J Affect Disord 2009 112 219-30. 

Major depressive episodes also occur in the context of bipolar disorder. The key difference is that persons with bipolar disorder also experience manic, hypomanic, and/or mixed episodes (see Chap. 36) during the course of their illness, whereas persons with MDD experience only major depressive episodes.3... 

Bipolar disorder is a mood disorder characterized by one or more episodes of mania or hypomania, often with a history of one or more major depressive episodes.1 It is a chronic illness with a course characterized by relapses and improvements or remissions. Mood episodes can be manic, depressed, or mixed. They can be separated by long periods of stability or can cycle... 

Bipolar disorders have been categorized into bipolar I disorder, bipolar II disorder, and bipolar disorder, not otherwise specified (NOS). Bipolar I disorder is characterized by one or more manic or mixed mood episodes. Bipolar II disorder is characterized by one or more major depressive episodes and at least one hypomanic episode. Hypomania is an abnormally and persistently elevated, expansive, or irritable mood, but not of sufficient severity to cause significant impairment in social or occupational function and does not require hospitalization. Most epidemiologic studies have looked at bipolar disorder of all types (bipolar I and bipolar II), or the bipolar spectrum, which includes all clinical conditions thought to be closely related to bipolar disorder. The lifetime prevalence of bipolar I disorder is estimated to be between 0.3% and 2.4%. The lifetime prevalence of bipolar II disorder ranges from 0.2% to 5%. When including the bipolar spectrum, the lifetime prevalence is between 3% and 6.5%.1... 

Bipolar disorder can be conceptualized as a continuum or spectrum of mood disorders and is not comprised solely of bipolar I disorder.9 They include four subtypes bipolar I (periods of major depressive, manic, and/or mixed episodes) bipolar II (periods of major depression and hypomania) cyclothymic disorder (periods of hypomanic episodes and depressive episodes that do not meet all criteria for diagnosis of a major depressive episode) and bipolar disorder, NOS. The defining feature of bipolar disorders is one or more manic or hypomanic episodes in addition to depressive episodes that are not caused by any medical condition, substance abuse, or other psychiatric disorder.1... 

Some, but not all, studies observe low CSF 5-HIAA in major depressive episodes. Numerous studies, though not all, have also reported no difference between patients with mania or depression in CSF 5-HIAA levels, consistent with both Prange et alls [15] permissive hypothesis for bipolar disorders and the indoleamine hypothesis. 

Two or more major depressive episodes Manic episode major depressive or mixed episode Major depressive episode + hypomanic episode Chronic subsyndromal depressive episodes Chronic fluctuations between subsyndromal depressive and hypomanic episodes (2 years for adults and 1 year for children and adolescents) Mood states do not meet criteria for any specific bipolar disorder... 

Screening patients for bipolar disorder A major depressive episode may be the initial presentation of bipolar disorder. It is generally believed that treating such an episode with an antidepressant alone may increase the likelihood of precipitation of a mixed/manic episode in patients at risk for bipolar disorder. Prior to initiating treatment with an antidepressant, adequately screen patients with depressive symptoms to determine if they are at risk for bipolar disorder. 

It is still debated whether patients with two previous episodes should receive maintenance treatment. Overall, maintenance treatment has been recommended for adult depressed patients with two episodes who have one or more of the following criteria (Depression Guideline Panel, 1993) (1) a family history of bipolar disorder or recurrent depression, (2) early onset of the first depressive episode (before age 20), and (3) both episodes were severe or life threatening and occurred during the past 3 years. Given that depression in youth has similar clinical presentation, sequelae, and natural course as in adults, these guidelines should probably be applied for youth with two previous major depressive episodes. 

Bipolar I disorder is characterized by a history of one or more manic episodes and one or more mixed or major depressive episodes. This category can be further sub-classified as either manic, hypomanic, mixed, or depressed in presentation. 

Mood symptoms of depression are associated with many conditions in addition to major depressive disorder, including mood and anxiety symptoms in schizophrenia, schizoaffective disorder, bipolar manic/depressed/mixed/rapid cycling states, organic mood disorders, psychotic depression, childhood and adolescent mood disorders, treatment-resistant mood disorders, and many more (see Chapter 10, Fig. 10-6). Atypical antipsychotics are enjoying expanded use for the treatment of symptoms of depression and anxiety in schizophrenia that are troublesome but not severe enough to reach the diagnostic threshold for a major depressive episode or anxiety disorder in these cases the antipsychotics are used not only to reduce such symptoms but hopefully also to reduce suicide rates, which are so high in schizophrenia (Fig. 11 — 53). Atypical antipsychotics may also be useful adjunctive treatments to anti-... 

Bipolar patients with substance abuse disorders are more likely to have an earlier onset of illness, mixed states, higher relapse rates, poorer response to treatment, higher suicide risk, and more hospitalizations. Approximately 10% to 15% of adolescents with recurrent major depressive episodes subsequently have an episode of mania or hypomania. 

Additionally, persons with bipolar disorder may experience episodes of depression similar to major depressive disorders. Bipolar disorder was previously referred to as manic-depressive illness, reflecting the existence of both manic and depressive episodes. Also, some patients with bipolar disorder have mixed episodes, with both manic and depressive symptoms concurrent. 

Though most persons who do not have bipolar disorder may consider the manic episodes to be beneficial and a positive experience, given the increased energy and euphoric mood, many patients with bipolar disorder find manic episodes to be very unpleasant, characterized by high levels of irritability and anxiety. Bipolar cUsorder, like major depressive cUsorder, is an episodic, recurrent convvcUtion, and in between episodes, the bipolar person may have function and behavior that appear completely normal. 

Bipolar disorder is characterized by episodes of mania or hypomania, which include hyperactivity, decreased need for sleep, and a euphoric or irritable mood. Additionally, persons with bipolar disorder may have episodes of depression similar to those seen in major depressive disorder. The lifetime prevalence of severe bipolar disorder is about 1% and 3-5% if milder cases are included, afflicting men and women equally. Both bipolar disorder and major depressive disorder tend to be episodic, and in the periods of time between episodes, persons may experience few or no symptoms. The etiology of bipolar disorder is predominately genetic, with a 70% concordance in monozygotic twins. The neurobiology of bipolar disorder is less well understood, and few animal models have been developed. Treatment of bipolar disorder usually involves mood stabilizer medications, including lithium, and the anticonvulsants valproate and carbamazepine. At times, antidepressant and antipsychotic medications are also used. 

One or more manic or hypomanic episodes with one or more major depressive episodes generally constitute the diagnosis of bipolar I disorder. Depression in bipolar disorder meets diagnostic criteria for major depression, with the exceptions of shorter duration and increased frequency. Depending on the cmrent presentation, bipolar disorder is subclassified as one of the following (DSM-IV) ... 

Bipolar disorder (manic-depressive illness) is one of the most common of the severe chronic psychiatric disorders. The cyclic mood disorder is characterized by recurrent fluctuations in mood, energy, and behavior encompassing the extremes of human experiences.Bipolar disorder differs from recurrent major depression (or unipolar depression) in that a manic, hypomanic, or mixed episode occurs during the course of the illness. Bipolar disorder is a lifelong illness with a variable course and requires both nonpharmacologic and pharmacologic treatments for mood stabilization. ... 

Bipolar disorder is frequently not recognized and treated for many years because of its fluemating course and episodic mood states. The onset of bipolar disorder is rare before puberty, but its incidence increases during late adolescence and into early adulthood (usually between the ages of 15 and 30). The average age of onset of a first manic episode is 21 for both men and women. The first episode in females is more likely to be a major depressive episode, whereas males are more likely to first experience a manic episode. ... 

In the bipolar II disorders, there have been one or more major depressive episodes and no history of either a manic or mixed episode. Bipolar II disorders are best described as alternating episodes of major depression and periods of hypomania (Maxman Ward, 1995). These hypomanic symptoms include increased levels of energy and mood that are not as intense as manic episodes, and clients with bipolar II disorder do not become delusional or requite acute hospitalization (American Psychiatric Association, 1994). 

According to the DSM-IV, clients with a diagnosis of cyclothymic disorder have milder experiences than those who suffer from bipolar disorders although the symptoms are more consistent and last for approximately two years. In order to be diagnosed with cyclothymic disorder, the client s history must indicate that he or she has not been without hypomanic and depressive symptoms for a period of two months (American Psychiatric Association, 1994) a client with a major depressive episode only should not be diagnosed as cyclothymia. 

For bipolar I disorder, 90% of individuals who experience a manic episode later have multiple recurrent major depressive, manic, hypomanic, or mixed episodes alternating with a normal mood state. 

Bipoiar Disorders. You must also distinguish the bipolar disorders from MDD. The distinction is particularly important in young adult patients given that nearly 10% of patients with an initial episode of major depression will go on to develop a bipolar illness. The devastating consequences of untreated mania coupled with the possibility that antidepressants may trigger manic episodes in susceptible individu-... 

Major Depressive Disorder (MDD). The distinction between MDD and BPAD is most problematic during the earliest episodes of illness and at younger ages of presentation. The first episode of bipolar illness is a depressive one in at least one-third of patients with BPAD. The younger the age of onset of an episode of depression, the greater the likelihood that the disease will progress to BPAD. 

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