Mixed mood episodes

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... 

Conventional antipsychotic drugs such as chlorpromazine and haloperidol have long been used in the treatment of acute mania. More recently, atypical antipsychotic drugs including aripiprazole, olanzapine, quetiapine, risperidone, and ziprasi-done have been approved for the treatment of bipolar mania or mixed mood episodes as monotherapy or in combination with mood-stabilizing drugs.25 Aripiprazole and olanzapine are also approved for maintenance therapy. The combination of olanzapine and fluoxetine is approved for treatment of bipolar depression. Quetiapine is approved for treatment of... 

Mixed mood episodes Symptoms of mania and depression occurring simultaneously or in close juxtaposition. 

Schizoaffective and mood disorder exclusion Schizoaffective disorder and mood disorder with psychotic features have been ruled out because either (1) no major depressive, manic, or mixed episodes have occurred concurrently with the active-phase symptoms or (2) if mood episodes have occurred during active-phase symptoms, their total duration has been brief relative to the duration of the active and residual periods. 

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... 

Another BRAD diagnostic modifier is the frequency of mood episodes or cycling. Patients who experience four or more episodes (depressed, hypomanic, or manic) per year are said to have rapid cycling BRAD. Rapid cycling patients are more likely to be female and, like those with mixed episodes, respond preferentially to certain anticonvulsants and perhaps atypical antipsychotics than to lithium. 

Bipolar disorder For the maintenance treatment of Bipolar I Disorder to delay the time to occurrence of mood episodes (eg, depression, mania, hypomania, mixed episodes) in patients treated for acute mood episodes with standard therapy. 

Bipolar mixed episode (previously known as mixed state, dysphoric mania, or depressive mania) is defined as the simultaneous occurrence of manic and depressive symptoms. Mixed mood states occur in up to 40% of all episodes, and are more common in younger and older patients and in females. Mixed episodes are often difficult to diagnose and treat because of the fluctuating clinical presentation. Patients with mixed states often have comorbid alcohol and substance abuse, severe anxiety symptoms, a higher suicide rate, and a poorer... 

Severe psychiatric illnesses such as bipolar disorder often manifest themselves during adolescence and young adulthood, and result in disruption of educational, occupational, marital, and other pursuits. Residual symptoms are often common between mood episodes, and more than one-half of bipolar patients manifest some degree of functional disability after the onset of the hlness. Poorer outcome is associated with rapid cycling, mixed states, concurrent alcohol and substance abuse, nonadherence to treatment, and poor psychosocial support. 

C There has never been another type of mood episode experienced such as manic episode, mixed episode, or hypomanic episode. If a history of these other mood-like episodes is reported, occurrence must be related to substance use, be treatment related or due to a general medical condition. 

Before discussing the different types of bipolar disorders, it is important to introduce the reader to what is commonly meant by a mood episode. These mood episodes are generally not diagnosed separately they are considered building blocks for the disorders that follow. The types of mood episodes that clients who suffer from the bipolar disorders may manifest are manic, hypomanic, major depressive, or mixed episodes (American Psychiatric Association, 1994). 

The last type of mood episode is referred to as the mixed episode. This episode is referred to as mixed because it generally meets the criteria for the manic and the depressive episode. The major difference is that it does not last for two weeks rather, it only lasts for approximately one week. In this type of episode the individual often experiences rapidly alternating moods with feelings of sadness, irritability, and euphoria. 

Prevention of recnrrence of affective disorder Insight into how best to use lithium to reduce the recurrence of new mood episodes continues to accrue. In long-term prospective study in five centers, the International Group for the Study of Lithium-Treated Patients examined the relative stability of patients with predominantly atypical features (n = 100 e.g. mixed states or rapid cycling) or more typical bipolar features (n = 142) over a mean of 10 years [16 f. There were no differences in the overall measures of morbidity in the two groups. 

BPAD Bipolar I >2 major mood episodes (at least one mania/mixed affective)... 

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... 

Optimize the dose of mood-stabilizing medication(s) before adding on benzodiazepines if psychotic features are present, add on antipsychotic ECT used for severe or treatment-resistant manic/mixed episodes or psychotic features... 

Sprinkle capsule 15, 25 mg Atypical Antipsychotics FDA approved for use in bipolar disorder Aripiprazole Abilify Tablets 5, 10, 15, Dosage should be slowly increased to minimize adverse effects (e.g., 25 mg at bedtime for 1 week, then 25-50 mg/day increments at weekly intervals) 10-30 mg/day once daily acute treatment of mania or mixed episodes due to lack of efficacy used as an adjunctive agent with established mood stabilizers Use as monotherapy or in... 

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). 

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... 

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. 

Divalproex sodium (sodium valproate) is now the most prescribed mood stabilizer in the United States. It is FDA approved only for the treatment of acute manic or mixed episodes, but it is often used as maintenance monotherapy for bipolar disorder. 

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. 

In the bipolar affective disorders (BPADs), periods of normal mood are interspersed with episodes of mania, hypomania, mixed states, or depression. BPAD differs from MDD in that there is a bidirectional natnre to the mood swings and, for many patients, the rate of cycling is more rapid in BPAD than MDD. The phases of BPAD inclnde mania, hypomania, and depression, though mixed states, the simultaneous presentation of symptoms of both mania and depression, are common. 

It is common for both the depressive and manic phases to occur simultaneously in what is termed a mixed state or dysphoric mania. During these mixed episodes, the patient s mood is characterized by symptoms of both a depression and mania. Mixed episodes often have a poorer outcome than classic euphoric mania and, as a rule, respond better to certain anticonvulsants and atypical antipsychotic drugs than to lithium. As many as 50% of admissions to inpatient psychiatric facilities for the treatment of manic episodes appear to be for mixed manic states. The recognition... 

In contrast to MDD, the bipolar disorders consist of episodes of depression and episodes of hypomania or mania. This poses a problem for treating the depressed phase of this illness, becanse, as noted earlier, antidepressants can trigger hypomania, mania, or mixed dysphoric mania and can increase the freqnency of manic episodes. Therefore, the hallmark of treating BPAD is the nse of mood stabilizers, with and withont snpplemental antidepressant therapy. Please refer to Table 3.16 for a comparison of the traditional mood stabilizers. 

Lithium remains the treatment of choice for bipolar patients who experience classic euphoric episodes of mania. Current evidence suggests that those with mixed episodes or rapid cycling episodes respond preferably to anticonvulsants or atypical antipsychotic drugs. In addition to its use as a mood stabilizer, lithium is effective in converting unipolar antidepressant nonresponders to responders. Finally, lithium may also be an effective treatment for patients with clnster headaches. 

Valproate (Depakote, Depakene). Valproate is an anticonvnlsant that has been demonstrated in multiple controlled clinical trials to be an effective mood stabilizer and, in fact, has obtained FDA approval for the treatment of acute mania. It appears to be particularly effective in bipolar patients who experience mixed episodes or rapid cycling or who have not responded well in the past to lithium. 

When selecting a mood stabilizer, four factors can guide selection (1) the phase of the current episode (i.e., euphoric mania vs. mixed mania), (2) the relative frequency of various episode types in the past as determined by review of the patient s life chart, (3) the patient s past response to particular mood stabilizers, and (4) the response of immediate family members (i.e., parents and siblings) to particular mood stabilizers. 

Mixed manic states can be characterized as the simultaneous presence of both a depressive and manic episode, meeting full criteria for both mood syndromes (except for duration) nearly every day for at least one week. This may be a relatively common occurrence, as noted earlier in the data of Goodwin and Jamison (i.e., 71% present with euphoria and 72% with depression), as well as others (30a) (9). Krasuski and Janicak (31, 32) reviewed various models to explain the interaction between mania or hypomania and depression and noted that aggression and anxiety may be important components, in addition to dysphoria, in defining mixed states. 

Schizoaffective disorder, characterized by concurrent symptoms of both schizophrenia (criterion A) and a mood disorder, meeting full criteria for a mood disorder, manic or mixed episode, can also pose a difficult diagnostic dilemma. Other criteria include a period of psychosis (2 weeks) in the absence of significant mood symptoms and mood symptoms should be present for a substantial proportion of an episode. Schizoaffective probands often have family members with both affective and schizophrenic disorders. 

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. 

Antidepressants modify the long-term course of bipolar disorder as well. When given with lithium or other mood stabilizers, they may reduce depressive episodes. Interestingly, however, antidepressants can flip a depressed bipolar patient into mania, into mixed mania with depression, or into chaotic rapid cycling every few days or hours, especially in the absence of mood stabilizers. Thus, many patients with bipolar disorders require clever mixing of mood stabilizers and antidepressants, or even avoidance of antidepressants, in order to attain the best outcome. 

FIGURE 7—35. Combination treatments for bipolar disorder (bipolar combos). Combination drug treatment is the rule rather than the exception for patients with bipolar disorder. It is best to attempt monotherapy, however, with first-line lithium or valproic acid, with second-line atypical antipsychotics, or with third-line anticonvulsant mood stabilizers. A very common situation in acute treatment of the manic phase of bipolar disorder is to treat with both a mood stabilizer and an atypical antipsychotic (atypical combo). Agitated patients may require intermittent doses of sedating benzodiazepines (benzo assault weapon), whereas patients out of control may require intermittent doses of tranquil-izing neuroleptics (neuroleptic nuclear weapon). For maintenance treatment, patients often require combinations of two mood stabilizers (mood stabilizer combo) or a mood stabilizer with an atypical antipsychotic (atypical combo). For patients who have depressive episodes despite mood stabilizer or atypical combos, antidepressants may be required (antidepressant combo). However, antidepressants may also decompensate patients into overt mania, rapid cycling states, or mixed states of mania and depression. Thus, antidepressant combos are used cautiously. 

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-... 

In a double-blind, placebo-controlled study, 175 manic or recently manic patients were stabilized over 8-16 weeks with lamotrigine 100-400 mg/day (n = 59), lithium in a dose sufficient to produce a serum concentration of 0.8-1.1 mmol/1 (n = 46), or placebo and were then randomized to continued treatment (94). Both lamotrigine and lithium were superior to placebo in prolonging the time to the next episode of any mood disturbance. Lamotrigine, but not lithium, was superior to placebo in prolonging the time to a depressive episode. Lithium, but not lamotrigine, was superior to placebo in prolonging the time to a manic, hypomanic, or mixed episode. 

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