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

160 A. Koukopoulos et al.With the introduction in 1851 of folie circulaire by Falret (1851), a significantnumber of melancholias became a component of a more complex disease entityand lost their nosologic independence. This nosographic evolution eventually ledto the creation of manic-depressive insanity by Kraepelin in 1899 and the definitivesubstitution of the concept of melancholia with that of depression. Many psychiatristshad proposed substituting the term melancholia, which had become toovague, with other terms such as tristimania, proposed by Rush (1830), lypemaniaby Esquirol (1838), dysthymia by Flemming (1844), and vecordia melaena byKahlbaum (1863).In the first edition 1883) ( of his textbook, Kraepelin placed melancholia activaamong the excited states and distinguished it from melancholia periodica, which isin any case marked by delirious or delusional ideas and anxious agitation. Onlymelancholia of circular insanity, marked by psychic and physical inhibition, correspondsto the clinical picture of the present disorder major depression. In the second(Kraepelin, 1887) and third (Kraepelin, 1889) editions, Kraepelin distinguishedbetween melancholia activa, very agitated, and melancholia simplex. In the fourthedition, published in 1893, he replaced melancholia activa with Angstmelancholie ,to emphasize better the component of anxiety in this condition. In the fifth edition(Kraepelin, 1896), he introduced melancholia of the age of involution: ‘‘with thename of melancholia we designate all pathological anxious depressions of olderage which do not represent parts in the course of other psychic disorders.’’ Theclinical picture also comprised delusions, especially of guilt but also of persecution,and hypochondriacal ideas. The similarity with the old melancholia agitata isevident. Kraepelin included Angstmelancholie in involutional melancholia.In the eighth edition (Kraepelin, 1913), Kraepelin subsumed involutional melancholiainto manic-depressive insanity, accepting the results of the catamnesticinvestigation carried out by his student Dreyfus (1907) on Kraepelin’s samepatients in Heidelberg. In essence, Dreyfus showed that involutional melancholiawas a mixed state of manic-depressive insanity. In his foreword to Dreyfus’sMelancholia, Kraepelin wrote with evident regret: ‘‘Nevertheless, it is to be foreseenthat the old clinical form of Melancholia, one of the oldest in psychiatry, willcompletely disappear because it contains mainly manic-depressive features.’’ Whathe could not have foreseen was that, by the end of the twentieth century, agitateddepression, which had replaced melancholia, in all likelihood would also lose itsstatus as a mixed state.In the following decades, the concept of melancholia was replaced in Europeanpsychiatry by the concept of endogenous depression and in the USA by the concept ofdepressive reaction according to Meyer’s (1951) idea of reaction types. Under theimpact of DSM-III (American Psychiatric Association, 1980), the term major depressionreplaced worldwide the terms of melancholia, endogenous depression, and