Bipolar Disorders: Mixed States, Rapid-Cycling, and Atypical Forms

94 E. Vieta et al.(5) psychotic depression; (6) continuous multigenerational familial transmission;(7) postpartum onset; and (8) early onset. They suggested that these episodes shouldbe called ‘‘pseudounipolar depression’’ and that the condition would show itsbipolar nature afterwards. Bourgeois et al.(1996) confirmed the significantly higherfrequency of these markers on bipolar disorder. Goldberg et al. (2001) foundthatdepressed patients with psychosis at the index depressive episode were significantlymore likely than non-psychotic patients to demonstrate mania or hypomania atfollow-up.With regard to outcome, Tsuang et al. (1979) found that, when marital,residential, occupational, and psychiatric symptoms were combined, outcomewas good in 64% of bipolar I patients, intermediate in 14%, and poor in 22%.Endicott et al.(1985) described a more chronic course in bipolar II than in bipolarI disorder; this difference not only accounted for affective symptoms but also forthe presence of other psychiatric problems between episodes. Coryell et al. (1989)found comparable degrees of psychosocial disability over time in bipolar II andbipolar I patients, although bipolar II patients were particularly likely to reportwork impairment at the end of a 5-year follow-up. Other authors have found thatbipolar I disorder was more incapacitating than bipolar II disorder (Vieta et al.,2002a). As far as social impairment and functioning between episodes are concerned,more than one-third of bipolar patients seem to have some chronicsymptoms; some of this pathology is sequelae of the episodes themselves, andmuch of it reflects the absence of prophylactic or poor treatment (Goodwin andJamison, 1990). Judd et al. (2002) studied the weekly symptomatic status ofpatients with bipolar I disorder during a prospective long-term follow-up; theresults showed that symptomatic structure was primarily depressive rather thanmanic, and subsyndromal and minor affective symptoms predominated. A studyby Tohen et al. (2000) with 219 cases of first episode of major affective disorderwith psychotic features (159 manic or mixed bipolar patients) showed thatsyndromal recovery was attained by most patients (98.6% of bipolar or mixedpatients) soon after hospitalization, but only one-third were functionally recoveredby 24 months (40.4% of bipolar or mixed patients); functional recovery wasassociated with older age at onset and shorter hospitalization. The psychosocialimpairment related to relapse persists for years in a great number of bipolarpatients (Coryell et al., 1993; Keck et al., 1998).Rapid cycling generally represents a transient phase in the course of bipolardisorder, with a prevalence rate lower than 20% in most studies (Akiskal et al.,2000). It is more likely to arise from a bipolar II base (Coryell et al., 1992;Baldessarini et al., 2000), thus alternating at least four depressive or hypomanicepisodes per year.