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

178 A. Koukopoulos et al.Table 7.3 Treatments associated with onset of agitated depressionTricyclic antidepressants 58Selective serotonin uptake inhibitors 45Monoamine oxidase inhibitors 4Other antidepressants 27Steroids 6Levothyroxine 4Caffeine 4Lithium withdrawal 4Neuroleptic withdrawal 2Maintenance antidepressants 7agents in Italy, but the possibility that these agents may be less agitating cannot beruled out. Six cases were associated with steroids, four with levothyroxine, four withexcessive caffeine intake, four with lithium withdrawal, and two with neurolepticwithdrawal. Eighty-three women (55% of all women) and 30 men (50% of all men)became agitated in association with the above-mentioned treatments. The previouscourse of these 113 patients was: bipolar I (BP) for 27 patients, BP-II for 47 patients,unipolar depression for 34 patients and five were first affective episodes. If wecompare them to the total numbers of the different groups, we find that 48% ofthe BP-I, 71% of the BP-II, and 50% of the unipolar patients had induced agitateddepressions. The preponderance of BP-II patients is to be noted. The age at onset ofthe mixed episode was 48.4 years for the induced group and 41.7 years for thespontaneous group. The duration of the mixed episode was 4 months for theinduced group and 5.4 months for the spontaneous group. There was no differencebetween the spontaneous and induced groups with regard to severity or outcome.Among our 212 agitated depressions, 68 (47 women and 21 men) also hadpsychotic symptoms. As psychotic symptoms we considered hallucinations,delusions, both congruent and non-congruent (true delusions and not merefears or doubts), and the presence of a state of mental confusion and grosslydisturbed behavior. Of these patients, 22 (32%) were spontaneous, i.e., the psychoticsymptoms emerged spontaneously and not in association with pharmacologicaltreatment. In the other 46 patients, the psychotic symptoms emerged inassociation with antidepressant treatment. Of these 46 patients, 30 patients had aBP-I course (54% of all BP-I patients), 14 had a course of BP-II (21% of all BP-IIpatients), 19 had a previous course of recurrent depression (28% of all unipolarpatients), and five were first affective episodes of psychotic depression. It should beunderlined that all the 14 BP-II patients who had a psychotic agitated depressionwere induced by antidepressants.