Bipolar Spectrum Disorder

Five or more of the following marks a Depressive Disorder: 

• Depressed mood—feeling low, sad or, as Shakespeare wrote, feeling life is dull, stale, flat and unprofitable. 
• Loss of pleasure in usual activities. 
• Weight or appetite changes. 
•  Change in sleep patterns. 
• Psychomotor retardation—slow movements, halting speech, just dragging around. 
• Fatigue, loss of energy. 
• Feelings of worthlessness or guilt 
• “Brain fog”—difficulty thinking, concentrating or forming thoughts, forgetfulness, trouble concentrating, indecisiveness, cloudy thinking. 
• Suicidal impulses. 

Two recent international studies involving over 8,000 patients are consistent with other estimates showing that almost 50% of depressed patients fall into the bipolar spectrum category. Bipolar Spectrum Disorder includes the following diagnostic categories:

• Bipolar I and Bipolar II Disorder characterized by mood swings alternating between normal mood, manic or hypomanic mood and depressed mood are found in 16% of depressed patients. 
• Bipolar I patients have one or more manic episodes that are so severe that hospitalization is almost always required for treatment. Mania is marked by at least three of the following symptoms: 
• Unrealistic, grandiose beliefs about one’s abilities or powers. 
• Rapid speech that makes it difficult for others to keep up. 
• Acting recklessly without thinking about the consequences. 
• Racing thoughts, jumping quickly from one idea to the next. 
• Distractibility marked by poor concentration and attention. 
• Impulsiveness, poor judgment, agitation 
• Sleeping very little but without loss of energy. 
• Extreme irritability or euphoric mood.
• Bipolar II patients have three or more of the same symptoms, as those with Bipolar I Disorder but the symptoms are not as severe and don’t last as long. These symptoms are called hypomanic (hypo = below). 
• A hypomanic episode is only required to persist for four days instead of seven as with a manic episode.
• Those in a hypomanic state can make bad decisions that harm relationships, careers and reputations, but they are able to perform without losing touch with reality, and they don't require hospitalization. 
• Antidepressant induced mania—depressed patients who become manic or hypomanic when taking an antidepressant. 
• Depression with mixed features is characterized by at least three of the following symptoms: 
• Elevated mood or a labile mood (rapid changes in mood). 
• Uncomfortable elevated energy makes one feel wired, restless or gives a sensation of feeling like “I'm crawling out of my skin.” 
• Impulsivity that often has a reckless tone such as quitting relationships or jobs, breaking things, aggressive driving or self-harm. 
• Patients may attempt to relieve depression by over spending, binge eating, drug addiction or watching pornography. 
• Unbearable anxiety—“Everything gets on my nerves. I’m tired and depressed in the day, then wired at night.” 
• Increased confidence such as demanding or intimidating behavior, or absolute certainty of beliefs. 
• Ruminating thoughts crowded with depressive or anxious feelings. 
• Rapid speech associated with dramatic expressions of suffering.  

Treatment of depression with mixed features:

• Antipsychotics for acute episodes such as aripiprazole (Abilify), risperidone (Risperdal) or lurasidone (Latuda). I prefer Abilify 5-15 mg daily because it is the most studied antipsychotic for this condition. 
• For maintenance therapy lamotrigine (Lamictal) 50-200 mg daily or lithium to keep serum levels 0.4-0.6 mEq/L for depression; 0.8-1.2 mEq/L for mania.