Two recent shareposts, “The Depression-Mania Two Step” (Part I and Part II ), zeroed in on a crucial fact that tends to be overlooked by clinicians, namely: Despite the fact that depression and mania present as polar opposites, the two can hardly be viewed as unrelated. For our own health and safety, they need to be seen together as part of the same cycling phenomenon.
Today’s depression is tomorrow’s mania, but there is another twist: Too often, depression fails to clear the room. Too often, mania doesn’t wait to be invited in. The two show up at once. The dance is over. A free-for-all breaks out.
The experts refer to the condition as a “mixed” episode or state. Sweet mania turns sour. Vegetative depression becomes animated. Those who have been through either describe the experience as akin to wanting to crawl out of your skin, of feeling the urge to grab the world by the throat and wring it.
I used to joke: “I get road rage a lot - and I don’t even drive.”
Amazingly, for a condition so pronounced, that causes so much distress, the DSM-IV is inexcusably vague, and so will its successor, the DSM-5 (due out in 2013), based on draft proposals issued last month. The good news is that the DSM-5’s criteria for a mixed state will be far less restrictive. In light of the fact that in all other respects DSM-IV bipolar and DSM-5 bipolar are virtually identical, this is a very significant development.
The current DSM recognizes mixed states only when full-blown depression is accompanied by full-blown mania. Thus: at least five (of nine) depression symptoms accompanied by at least four (of seven) mania symptoms. Technically, then, only those with bipolar I qualify.
But in the real world, individuals may experience depression accompanied by only two or three mania/hypomania symptoms. Or mania with just two or three depression symptoms. Don’t these symptoms somehow count?
Yes, says Ellen Frank PhD of the University of Pittsburgh. In an interview several years ago, Dr Frank explained to me that “even isolated symptoms that don’t cluster together to create episodes may be important." A 2004 study she collaborated on with Giovanni Cassano MD of the University of Pisa found that just one symptom of mania (the symptom list in the study was much longer and more refined than the DSM list) in unipolar depression increased risk for suicidal ideation 4.2 percent. More symptoms kept upping the risk.
So what do we do with these so-called unipolars? Treat them as if they had pure depression? According to Hagop Akiskal MD of UCSD, in a journal article, “the nonrecognition of depressive mixed state is nothing short of a clinical tragedy because these are the very ‘unipolar’ depressive patients who are likely to do poorly on antidepressants …”
These would be your agitated depressions, an unbearable energized psychic pain.
Looking at it from the mania/hypomania side of the divide: In a 2003 grand rounds lecture at UCLA, Trisha Suppes MD, PhD of Stanford described having an epiphany while reading the DSM criteria for hypomania. "I said, wait, where are all those patients of mine who are hypomanic and say they don’t feel good?"
