Upside Down— Depression and Hypomania



Upside Down— Depression and Hypomania





Although the focus of this book is elevated mood, any discussion of hypomania must include its interface with depression. Whether the appearance of depressed symptoms is discrete or concurrent with episodes of elevated mood, the diagnosis and treatment of elevated mood must take into account its relationship to depression. The prevalence of depression in patients with elevated mood occurs so frequently that this topic deserves special attention here. Depressive symptoms occurring simultaneously with elevated mood are covered both in this chapter and under mixed affective states in Chapter 8.

If one were to construct a “Top Ten List” of the reasons that patients with elevated mood present for mental health treatment, it might appear like the list in Table 4.1.

Because the presenting complaints of elevated mood, patients have not been systematically researched or quantified, experts might disagree on the exact order of this “top ten list,” but few would dispute that depression is, by far, the most common reason for presentation. Because evidence of elevated mood may be only commingled with symptoms of depression in patients with mixed states, or may only be historically evident but not present at the time of evaluation, careful diagnostic exploration is crucial.

Data gathered in several large-scale studies has shown that depression is extraordinarily common in patients with elevated mood. Judd, Akiskal et al. demonstrated that patients with bipolar I disorder spent an average
of one third of their time in a depressed state (1). Another study by this same group (2) showed that patients with bipolar II disorder spent at least half of their time in a clinically depressed state. In a naturalistic perspective, 7-year follow-up study of 908 patients with bipolar disorder, Suppes et al. looked for subtle signs of hypomania and depression as scored on the Young Mania Rating Scale and the Inventory of Depressive Symptomatology (3). Hypomania was present in 392 (43%) of these patients. In those patients with hypomania, 71% presented with depression mixed with hypomania during at least one visit. Overall, in 57% of the visits in which hypomania was present, depressive symptoms also occurred.








TABLE 4.1 Top 10 reasons for persons with elevated mood to present for treatment























• Depression


• Depression


• Depression


• Depression


• Depression


• Sleeplessness


• Anxiety


• Alcohol/drug use and abuse


• Irritability and explosiveness


• Problems with relationships


Bauer et al. (4) performed a cross-sectional analysis of 441 individuals with bipolar disorder treated at an American health maintenance organization and investigated the distribution of manic and depressive symptoms in that population. They found that clinically significant depressive symptoms occurred in 94.1% of those with mania or hypomania whereas 70.1% of those in a depressive episode had clinically significant manic symptoms.

Beyond the frequency of depression in patients with bipolar disorder, as documented by the studies mentioned in the preceding text, there is now evidence that depressed episodes incur a significant level of psychosocial impairment. Judd et al. (5) followed 158 patients with bipolar I disorder and 133 patients with bipolar II disorder for 20 years. Their findings suggest that any level of depression in patients with bipolar disorder is more disabling than any form of mania, further highlighting the necessity of identifying depression as well as elevated mood.

Perlis et al. (6) followed a subset of 1,469 patients who had been symptomatic for bipolar disorder with 58% achieved recovery. During a 2-year
follow-up period, 49% of those who had recovered subsequently experienced recurrences with twice as many patients developing depressive episodes as manic/hypomanic/mixed episodes combined. These episodes of depression also occurred significantly earlier than manic or hypomanic recurrences. Their data suggests that residual mood symptoms at the time of recovery are a “powerful predictor” of recurrence. The risk of a depressive relapse increased by 14% for every Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV) depressive symptom still present at the time of recovery. This led the researchers to conclude “Overall, these results suggest that despite modern evidence-based treatment, bipolar disorder remains a highly recurrent, predominantly depressive illness.” Therefore, the principle of treating depression to full remission, the clinical goal for major depressive episodes, also appears to apply to depressive episodes within the context of a bipolar disorder.


Differentiating a major depressive episode from the depression of bipolar disorder

It is helpful to think of depression not as a diagnosis but rather as a constellation of symptoms that can be present in multiple psychiatric disorders. Just as sepsis is a constellation of symptoms that requires further diagnostic assessment to determine etiology, “depression” should not be considered an end point. Once a depressive constellation of symptoms is identified, further clinical assessment is necessary to fully solve the diagnostic puzzle. A constellation of depressive symptoms could (in our current nomenclature) reflect unipolar depression, dysthymic disorder, bipolar I disorder, bipolar II disorder, a mixed affective state, a side effect to medications such as interferon or corticosteroids, or a response to certain viral illnesses such as mononucleosis or hepatitis. As this text focuses on elevated mood, we will concentrate our discussion on the interface between depressive symptoms and elevated mood in primary mood disorders.

Until there is solid endophenotypic and/or genotypic data to assist in more precisely diagnosing various types of depressed mood as described in Chapter 2, we must depend on clinical signs and symptoms and solid diagnostic skills to differentiate bipolar depression from unipolar depression. Even with potentially useful phenotypic signs and symptoms, it is important to realize that these are still only broad generalizations.

Some of the other signs that may assist clinicians in distinguishing unipolar depression from bipolar depression include differences in the course of the depressive symptoms as well as which symptoms are present. These are shown in Tables 4.2, 4.3, and 4.4 adapted from (7,8,9).


Searching for historic periods of elevated mood

When a patient presents with depression, it is important not to limit diagnostic queries to symptoms and time courses of depressive episodes alone. In
addition to the diagnostic principles discussed in Chapter 3, each depressed patient should be asked specifically about the presence of mood shifts including the frequency, intensity, rapidity, and the character of the changing moods.

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Jul 29, 2016 | Posted by in GENERAL | Comments Off on Upside Down— Depression and Hypomania
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