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

16The use of atypical antipsychotic agentsin the treatment of diagnostic subgroupsof bipolar disorder: mixed and purestates, psychotic and non-psychoticRobe rt W. Baker1 1 2, Leslie M. Schuh and Mauricio Tohen1 Lilly Research Laboratories, Indianapolis, IN, USA2 Lilly Research Laboratories, Indianapolis, IN, and Harvard Medical School, Belmont, MA, USAIntroductionThere are many challenges in treating bipolar disorder, including confrontingmarked variability in symptoms between patients, as well as highly differingsymptomatic presentations within an individual patient’s course of illness.Diversity of presentation and course is potentially quite important to prognosisand treatment selection, though the relevance has not been consistently welldefined in empirical research. This chapter reviews controlled findings regardingthe impact of variant bipolar presentations to predicting treatment response withatypical antipsychotic agents.Classic bipolar I disorder consists of euthymic periods punctuated by episodesof mania or major depression. Interindividual variability is manifest in differingseverity, length, and frequency of manic and depressive episodes and the degree ofsymptom relief occurring between acute episodes. There are, of course, manyvariations on the classic pattern, such as the concurrent dysphoric and manicsymptoms of mixed states, subsyndromal presentations, or the markedly frequentepisodes of rapid cycling. Bipolar disorder is also commonly complicated bypsychiatric comorbidity, such as psychosis, as well as substance abuse or physicaldisorders. Not surprisingly, patients with bipolar disorder have increased mortalityfrom suicide, accidents, substance-abuse-related causes, and various medicaldiseases (Baldessarini, 2002).Variant presentations may be more difficult to treat than classic bipolar depressionor mania. First, these presentations often broaden the range of target symptoms# Cambridge University Press, 2005.