Manic depression Course

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... 

Bruce Bower. Pushing the Mood Swings Social and Psychological Forces Sway the Course of Manic Depression. Science News. 157 (Apr. 8, 2000) 232-233. 

Bipolar disorder, previously known as manic-depressive illness, is a cyclical, lifelong disorder with recurrent extreme fluctuations in mood, energy, and behavior. Diagnosis requires the occurrence, during the course of the illness, of a manic, hypomanic, or mixed episode (not caused by any other medical condition, substance, or psychiatric disorder). 

The term "bipolar disorder" originally referred to manic-depressive illnesses characterized by both manic and depressive episodes. In recent years, the concept of bipolar disorder has been broadened to include subtypes with similar clinical courses, phenomenology, family histories and treatment responses. These subtypes are thought to form a continuum of disorders that, while differing in severity, are related. Readers are referred to the Diagnostic and Statisticial Manual of Mental Disorders of the American Psychiatric Association (DSM-IV) for details of this classification. 

Goodwin FK, Jamison KR Course and outcome, in Manic-Depressive Illness. New York, Oxford University Press, 1990a, pp 127-156 Goodwin FK, Jamison KR Manic-Depressive Illness. New York, Oxford University Press, 1990b... 

Joffe RT, Swinson RP Total sleep deprivation in patients with obsessive-compulsive disorder. Acta Psychiatr Scand 77 483-487, 1988 Joffe RT, Swinson RP, Levitt AJ Acute psychostimulant challenge in primary obsessive-compulsive disorder. J Chn Psychopharmacol 11 237-241, 1991 Johns CA, Greenwald BS, Mohs RC, et al The chohnergic treatment strategy in aging and senile dementia. Pharmacological Bulletin 19 185-197, 1983 Johnson BB, Naylor GJ, Dick EG, et al Prediction of chnical course of bipolar manic depressive illness treated with hthium. Psychol Med 10 329-334, 1980... 

Keller MB. The course of manic-depressive illness. J din Psychiatry 1988 49 4-7. 

Lundquist, G. 1945, Prognosis and course in manic depressive psychosis, Acta Psychiatr.Neurol.Scand. Suppl., vol. 35, pp. 1-96. 

Untreated manic-depressive illness is, by any measure, gravely serious— complex in its origins, diverse in its expression, unpredictable in its course, severe in its recurrences, and often fatal in its outcome. 

Since the 1950s, the psychiatric community has had the benefit of antimanic and antidepressant medications to treat manic-depressive illnesses. These medications were developed using the work of Emil Kraepelin, a German physician who wrote about mental illness in the late nineteenth century and early part of the twentieth century. Kraepelin had carefully noted distinguishing symptoms among mental patients and had followed the course of the various illnesses in many of them. He was the first to distinguish what he called dementia praecox, now called schizophrenia, and was able to differentiate this illness from manic depression. 

Lawrence, orders of magnitude less articulate than Oppenheimer, was also fiercely driven the question is what drove him. A paragraph from a letter to his brother John, written at about the same time as Oppenheimer s essay, is revealing Interested to hear you have had a period of depression. I have them often—sometimes nothing seems to be OK—but I have gotten used to them now. I expect the blues and I endure them. Of course the best palliative is work, but sometimes it is hard to work under the circumstances. That work is only a palliative, not a cure, hints at how blue the blues could be. Lawrence was a hidden sufferer, in some measure manic-depressive he kept moving not to fall in. 

In the study of the response of nonlinear systems to external periodic perturbations there exists a dual search, that for universal relations and that for responses specific to a particular reaction mechanism. System mathematicians are, of course, intrigued by commonalities and universal relations. As an example, the similarities of alkali atoms and irons are of course remarkable. However, the chemists and biologists must also face the task of differences in the behavior of the sequence in the periodic table. Lithium carbonate controls manic depressive illness effectively, whereas the other alkali carbonates do not (nor do other alkali salts other than lithium salts). We have the same duality of interest in complex reaction mechanisms. Bifurcations, limit cycles, critical slowing down, occur in many nonlinear systems and have common features and universal laws. To the extent that these hold we find out little about the specific reaction mechanism of a given system and we seek properties which are specific to such reaction mechanisms. 

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... 

The essential feature of major depressive disorder is a clinical course that is characterized by one or more major depressive episodes without a history of manic, mixed, or hypomanic episodes. Dysthymic disorder is a chronic disturbance of mood involving depressed mood and at least two other symptoms, and it is generally less severe than major depressive disorder. This chapter focuses exclusively on the diagnosis and treatment of major depressive disorder. 

The primary indication for ECT in adolescents is the short-term treatment of mood symptoms, depressive or manic (Walter et al., 1999). Mood symptoms in the course of major depression, psychotic depression, bipolar disorder, organic mood disorders, schizophrenia, and schizoaffective disorder respond well to ECT. Psychotic symptoms in mood disorders also respond well to ECT whereas the effectiveness of ECT in the treatment of psychotic symptoms in schizophrenia is doubtful. There are suggestions that other uncommon clinical conditions in adolescents such as catatonia and neuroleptic malignant syndrome also benefit from ECT. The effectiveness of ECT seems to lessen when there is a comorbid personality disorder or drug and/or alcohol problems. There are very few data about usefulness on prepubertal children. 

Strober, M., Lampert, C., Schmidt, S., and Mottell, W. (1993) The course of major depressive disorder in adolescents I. Recovery and risk of manic switching in a follow-up of psychotic and nonpsychotic subtypes. J Am Acad Child Adolesc Psychiatry 32 34 2. 

These circumstances have important implications for management because drug treatment of the depressive phase may precipitate a manic episode, rapid cycling, or a more virulent course of the illness ( 3). Thus, if bipolar disorder is known or suspected, patients are best managed acutely, as well as for maintenance/prophylaxis, with a mood stabilizer. An antidepressant should be added only when necessary and for the shortest time frame required to alleviate the depressive symptoms. 

Schizophrenia-related disorders, such as schizophreniform disorder, can closely mimic an acute exacerbation of mania. Attention to premorbid personal and family history may help differentiate them from mood disorders. A definitive diagnosis may not be possible, however, until the course of the illness is followed for a period of time. Clinical clues include the propensity of bipolar manics (in contrast to schizophrenics) to demonstrate pressured speech, flight of ideas, grandiosity, and overinclusive thinking. Hallucinations are less common than delusions in both mania and depression, with delusions normally taking on the qualities of expansivity, hyperreligiosity, or grandiosity. Delusions are also relatively less fixed than in schizophrenia. 

Longitudinal observations indicate that, early in the course of the illness, various phases (depressive, hypomanic, manic) are often associated with identifiable external stressors. Over time, however, patients may begin to show spontaneous fluctuations in mood, as well as increased frequency and severity of episodes. 

Keller et al. (46) were also surprised to find that 75% of the nonrecovered patients had been treated with sustained, high levels of drug and/or somatic therapies and concluded that mixed or cycling patients have a more pernicious course and require more effective therapies. In addition, to achieve earlier remission, clinicians should begin aggressive treatment in the initial symptomatic stages, because the purely manic and depressed groups also had severe episodes despite adequate... 

During the depressive phase, patients will often require the addition of an antidepressant. This may further complicate their management, however, because there is the possibility of propelling patients into a manic episode, a rapid cycling course, or a more treatment-resistant phase of their illness ( 75, 76). 

The longitudinal course of bipolar illness is also characterized by many recurrent episodes, some predominantly depressive, some predominantly manic or hypomanic, some mixed with simultaneous features of both mania and depression (Fig. 5—5) some may even be rapid cycling, with at least four ups and/or downs in 12 months (Fig. 5—6). There is worrisome evidence that bipolar disorders may be somewhat progressive, especially if uncontrolled. That is, mood fluctuations become more frequent, more severe, and less responsive to medications as time goes on, especially in cases where there has been little or inadequate treatment. 

---