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Table 6-1 Mixed states of mania and depression

Are mood disorders progressive?

One of the major unanswered questions about the natural history of depressive illnesses is whether they are progressive ( and ). Some observers believe that there is an increasingFigures 6-23 6-24 number of patients in mental health practices who have bipolar spectrum illnesses rather than unipolar illnesses, especially compared to a few decades ago. Is this merely the product of changing diagnostic criteria, or does unipolar depression progress to bipolar depression ( )? AFigure 6-23 corollary of this question is whether chronic and widespread undertreatment of unipolar depression, allowing residual symptoms to persist and relapses and recurrences to occur, results first in more rapidly recurring episodes of major depression, then in poor inter-episode recovery, then progression to a bipolar spectrum condition, and finally to treatment resistance ( ). ManyFigure 6-23 treatment-resistant mood disorders in psychiatric practices have elements of bipolar spectrum disorder that can be identified, and many of these patients require treatment with more than antidepressants, or with mood stabilizers and atypical antipsychotics instead of antidepressants. For patients already diagnosed with bipolar disorder, there is similar concern that the disorder may be progressive, especially without adequate treatment. Thus, discrete manic and depressive episodes may progress to mixed and dysphoric episodes, and finally to rapid cycling, instability, and treatment resistance ( ). The hope is that recognition and treatment of both unipolar and bipolarFigure 6-24 depressions, causing all symptoms to remit for long periods of time, might prevent progression to more difficult states. This is not proven, but is a major

Table 6-1 Mixed states of mania and depression

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Figure 6-19. . Bipolar V is defined as major depressive episodes with hypomanic symptoms occurringBipolar V during the major depressive episode but without the presence of discrete hypomanic episodes. Because the symptoms do not meet the full criteria for mania, these patients would not be considered to have a full mixed episode, but they nonetheless exhibit a mixed presentation and may require mood stabilizer treatment as opposed to antidepressant monotherapy.

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hypothesis in the field at the present time. In the meantime, practitioners must decide whether to commit “sins of omission,” and be conservative with the diagnosis of bipolar spectrum disorder, and err on the side of undertreatment of mood disorders, or “sins of commission,” and overdiagnose and overtreat symptoms in the hope that this will prevent disease progression.

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