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

182 A. Koukopoulos et al.excitatory and depressive phenomena do not simply coexist but are interdependentin their emergence and evolution, and are probably caused by the samepathophysiological alteration. An additional explanation could be that, once theexcitatory phenomena have subsided, the highly energetic temperament of thesepatients quickly overrides the depression, obviating the need for antidepressanttreatment. In other cases depression sets in and antidepressant treatment isnecessary for weeks or months. This biphasic evolution of many cases of agitateddepression may be the basis of the doubts and hesitations of many clinicians aboutits treatment (Erfurth et al., 2001).ConclusionsAgitated depression should be considered a mixed affective state given its phenomenologyand response to treatments. Antidepressants worsen the condition ofthese patients and, in many cases, induce agitation or psychosis in cases withotherwise simple depression. The authors propose new diagnostic criteria foragitated depression and introduce the term minor agitated depression for thecases with psychic agitation without motor agitation or psychotic symptoms.Three forms of agitated depression (mixed depression) are described: (1) psychoticagitated depression; (2) agitated depression with psychomotor agitation; and(3) minor agitated depression. All these forms may be induced or aggravated byantidepressants and improve with mood-stabilizing and antipsychotic treatments,as well as ECT.REFERENCESAkiskal, H. S. (1992). The distinctive mixed states of bipolar I, II, and III. Clin. Neuropharmacol.,15 (suppl. 1), 632A–3A.Akiskal, H. S., Hantouche E. G., Bourgeois, M. L. et al. (1998). Gender, temperament, and theclinical picture in dysphoric mixed mania: findings from a French national study (EPIMAN).J. Affect. Disord., 50, 175–86.American Psychiatric Association (1968). Diagnostic and Statistical Manual of Mental Disorders.Washington, DC: American Psychiatric Association.American Psychiatric Association (1980). Diagnostic and Statistical Manual of Mental Disorders.Washington, DC: American Psychiatric Association.American Psychiatric Association (1987). Diagnostic and Statistical Manual of Mental Disorders.Washington, DC: American Psychiatric Association.American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders.Washington, DC: American Psychiatric Association.Aretaeus Cappadox (1735). De Causis et Signis Morborum. Lugduni Batavorum: JanssoniosVander.