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

181 Agitated depression: spontaneous and inducedThis has also been observed by other authors (Glassman et al., 1975; Spiker et al.,1985). We treated this pure depressive phase with antidepressant drugs. In thispure depressive phase, any antidepressant treatment may be effective. The traditionalamitriptylin seems the most suitable because it is the least likely to triggeragitation. In our view the mixed depressive phase followed by a simple depressioncorresponds to the pattern of manic-depressive cycle starting with mania andfollowed by depression. There, too, the manic phase is treated with antimanicagents and the depression is susceptible only to antidepressant treatments.Agitated depression was followed by simple depression in 64 cases (30%). Intheir previous course, these patients were bipolar I (n ¼ 20), bipolar II (n ¼ 17),unipolar depression (n ¼ 22), and five cases were first episode agitated depression.We hold that it is no coincidence that 28% of bipolar patients present the samecycle pattern consisting of mania followed by depression, which in most cases is ofa simple or clearly inhibited type (Kukopoulos et al., 1980).Many clinicians, on an empirical basis, have always treated these patients firstwith neuroleptics and then with antidepressants and many authors, starting withKlein and Davis (1969), have recommended this line of treatment. ECT is evenmore effective in mixed depressive states than in non-mixed depressions. The lessfrequent use of ECT in recent years (in Italy, unfortunately, for political and notmedical reasons), coupled with the widespread use of antidepressants, has worsenedthe condition of these seriously ill patients, who often suffer longer durationof episodes, longer hospitalization, and higher risk of suicide.It may be argued that the treatment of the agitated phase with neuroleptics andother antimanic agents favors the onset of a depressive phase, but this is also truefor the typical mania–depression cycle where it is clear that neuroleptics onlyaccentuate the natural evolution of the manic–depressive cycle, i.e., the depression,more or less severe, that follows the manic phase. ECT, with its antidepressant andantimanic action and its particular effectiveness in mixed depressive states, hadcloaked the essential difference between mixed and simple depression. But as far asresponse to treatment is concerned, the same thing happened with the frequentlybiphasic course of agitated and psychotic depression. Glassman et al.(1975) madethe first observation of a simple depression following a psychotic depression afterneuroleptic treatment in 1975, though their interpretation was different fromours. ECT sweeps away mixed and simple depression in the course of the sameseries of sessions, and this is conceivable. But what reveals the singular nature ofmixed depressive states is the fact that, often, after one to three ECT sessions, thewhole syndrome resolves abruptly. We have seen complete recovery after only oneECT. This outcome seems analogous to that obtained in milder cases after a fewdays of neuroleptic–benzodiazepine treatment and especially with olanzapinetreatment. This rapid response is hard to explain but it demonstrates that