It’s All About the Mood Spectrum: Part I, Recurrent Depression

John McManamy Health Guide
  • Bipolar disorder is a relatively new term. Various research groups had been teasing out “unipolar” depressions from “bipolar” depressions, but it wasn’t until the DSM-III of 1980 that bipolar disorder was recognized a separate illness from unipolar depression. Contrary to popular belief, the term bipolar is not synonymous with manic depression, and therein lies a lot of confusion.

    The pioneering diagnostician Emil Kraepelin, who coined the term manic depression, saw the illness as a continuous spectrum that included both unipolar depression as well as what we now call bipolar disorder. As Frederick Goodwin MD, former director of the NIMH and co-author (with Kay Jamison) of the definitive work on bipolar disorder, recently told me:
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    “In his system, affective disorders were divided into the highly recurrent and the less recurrent or non- recurrent forms. So what he meant by manic depressive illness was recurrent affective disorder.”

    By recurrent, Dr. Goodwin means more than one episode. So when we are looking at depression, we are looking for a pattern of many episodes of relatively short duration when compared to chronic depression. Why focus on depression? Because in the middle of the spectrum where so-called depression meets the less obvious forms of bipolar, it is notoriously difficult to spot manic or hypomanic episodes.

    Hypomania is the diagnostic threshold for bipolar II, but the psychiatric community is only just beginning to wake up to the fact that these patients are depressed way more than they are hypomanic, 37 times more often according to one study, 50 times more often according to another. When I hear these numbers bandied about at psychiatric conferences I can literally hear gasps from the audience.

    Trying to find evidence of bipolar in a person who seems to do nothing but cycle in and out of depression, then, can be as fruitless an undertaking as trying to find a brain cell in Jessica Simpson’s empty head. Should we even be bothering to look for hypomania? How about simply something closer to normal? Why don’t we forget hypomania entirely for the time being and simply concentrate on the depressions?

    What we are looking for is evidence of a cycle. Think of all those depressions, then, not so much as separate episodes, but as a cycle that resembles bipolar disorder. The “ups” may be less pronounced, but the depressions, oh, those depressions, one after another.

    So should these highly recurrent depressions be re-classified as bipolar II? Hagop Akiskal MD of the University of California at San Diego would like to do so. Dr Akiskal over the years has been the leading proponent of overhauling the DSM and returning to Kraepelin. Basically, if it cycles like bipolar, it must be bipolar.

    Dr. Goodwin, on the other hand, is less inclined to extend the bipolar diagnosis to a group of people who never danced on tables. But this is a minor quibble. What’s important is that both these leading authorities are in agreement on the fact that there is a large group of patients that psychiatry is ignoring and probably incorrectly treating. Both agree that the DSM gives us no insight. Both are strong advocates of what can best be described as the mood spectrum approach.

  • Both Drs. Goodwin and Akiskal will be sharing the same podium at a psychiatric conference I will be attending in Toronto next week. I will be there an hour ahead of time to make sure I get a seat. Till then …
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    Tell us your thoughts about the confusion over manic depression and bipolar disorder in the message boards.

Published On: May 19, 2006