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

176 A. Koukopoulos et al.The temperamental reactions of all persons are often similar in type but they arenot constant. Other factors contribute, such as life situation and age. Old age hasoften been recognized as the age at which agitated and anxious depressions are morefrequent. Involutional melancholia is an atypical example. The relationship betweenaffective disorders and age is certainly very complex. The perimenopausal years, forexample, are a time of increased emotional lability and reactivity. The mean age atonset of agitated depression in our sample was 45.9 for men and 44.9 for women.Diagnostic criteria of agitated depressionFull depressive syndrome and inner unrest are both essential elements of thissyndrome. The presence of motor agitation is sufficient to make the diagnosis,as in the RDC criteria, because it also confirms the presence of psychic agitation.The absence of motor agitation creates the diagnostic problem of distinguishinganxiety from the particular inner unrest of agitated depression. In order to clarifythe differential diagnosis between anxiety and inner agitation, pending moresystematically validated criteria, we used a set of criteria different from thatproposed in our previous paper (Koukopoulos, 1999). Along with major depressionand inner agitation, at least three of the following symptoms must be present:(1) racing or crowded thoughts(2) irritability or an unprovoked feeling of rage(3) absence of signs of retardation(4) talkativeness(5) dramatic descriptions of suffering or frequent spells of weeping(6) mood lability and marked emotional reactivity(7) early insomniaSuch symptoms are of an excitatory, not depressive, nature and indicate the absenceof inhibition. Early insomnia is often sustained by racing or crowded thoughts. Thesecriteria were, however, validated by the external criterion of the effect of antidepressanttreatments. A total of 113 cases had simple depressions that became agitated(with at least three of the above symptoms) when treated with antidepressants.Patients and methodDuring the years 1990–1999 we have examined and treated 212 (152 women; 72%)patients suffering from agitated depression as defined above. All met DSM-IIIRcriteria for major depression. Sixty-seven cases presented with agitated depression(non-psychotic) with psychomotor agitation. The others suffered from minoragitated depression (77 cases), as defined above, and psychotic agitated depression(68 cases). Transient agitated depressive states were not included. A minimum of