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

179 Agitated depression: spontaneous and inducedLatent agitated depressionThere are cases of depression that, though without manifest psychic or motoragitation and not delusional, rapidly become agitated after the institution ofantidepressant drug treatment. All antidepressants can induce this effect incertain patients but the most rapid triggering is seen with selective serotoninreuptake inhibitors. Probably the cases of suicidal or other violent acts attributedto selective serotonin reuptake inhibitors in recent years may be due to theagitation induced by the drugs in patients who were already agitated or proneto agitation, and not due to adverse pharmacological reactions. Reading theclinical descriptions of these cases, it is clear that the suicidal ideas have emergedfrom a state of agitated depression (Teicher et al., 1990; Healy,1994), thepsychomotor component of which is often seen as akathisia (Drake andEhrlich, 1985). We propose the term latent agitated depression for these depressionsprone to agitation. How can they be identified? According to our observations,the most reliable signs are:1. total lack of inhibition in speech and movement2. rich description of their depressive suffering3. early or middle insomnia rather than late insomniaThese signs are not of absolute value but may suffice to suspect a latent agitateddepression and make one more cautious with treatment. One should start with anantimanic, antianxiety medication, or, if antidepressants are used in the beginning,a sedative should be added. In any case, sedative treatment is the best protectionagainst suicide, as Fawcett et al. (1993) emphasize.TreatmentIn the majority of our depressed patients, the emergence of psychotic features,motor agitation, or intense psychic agitation was associated with antidepressanttreatments or was exacerbated by them. The basic rule for their treatment,therefore, was to suspend antidepressants if they were being administered ornot to administer them until psychotic symptoms and agitation had subsided.The best results are obtained by initiating treatment with old or new neuroleptics,benzodiazepines, anticonvulsants, and lithium. Perhaps the most rapideffect is achieved by a combination of neuroleptics and benzodiazepines.Haloperidol and clonazepam are equally effective. In cases of minor agitateddepression, even lower doses of haloperidol and clonazepam, such as 2 mg, maybe effective in as little as 48 h. In more resistant cases, higher doses are required.ECT is rapidly effective. Table 7.4 shows the treatments given to the patients whofully recovered.