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

35 Beyond major depression and euphoric maniastates of agitated depression as belonging to the mixed states. However, accordingto Kraepelin’s concept of manic-depressive insanity, a distinction between bipolaror unipolar was not important. According to his concept, all affective disordersbelong together, and the mixed states were for Kraepelin the strongest argumentfor such a unification (Kraepelin, 1899). But the rebirth of the unipolar–bipolardistinction in the mid-1960s again raised the question of the nature of agitateddepression. For Koukopoulos et al., the answer is clear: agitated depression is abipolar disorder belonging to the mixed states (Koukopoulos and Koukopoulos,1999 ; see Chapter 7) . They concluded:Agitated depression should be considered a mixed affective state given its phenomenology andresponse to treatments. Antidepressants worsen the condition of these patients and, in manycases, induce agitation or psychosis in cases with otherwise simple depression. The authorspropose new diagnostic criteria for agitated depression and introduce the term minor agitateddepression for the cases with psychic agitation without motor agitation or psychotic symptoms.Three forms of agitated depression(mixed depression) are described:(1) psychotic agitated depression(2) agitated depression with psychomotor agitation and(3) minor agitated depression.All these forms may be induced or aggravated by antidepressants and improve with moodstabilizingand antipsychotic treatments, as well as ECT.Akiskal coined the term ‘‘hyperthymic depression’’ (Akiskal and Pinto, 2000),which is similar to Koukopoulos‘s ‘‘excited depression’’ (Koukopoulos et al., 1992).According to Akiskal and Pinto (2000), hyperthymic depression is a subtype ofbipolar disorder (bipolar IV). For this category, they proposed using patientswith clinical depression that occurs later in life and that is superimposed on alifelong hyperthymic temperament. They are typically males in their 50s whose lifelongdrive, ambition, high energy, confidence, and extroverted interpersonal skillshelped them to advance in life, to achieve success in a variety of business domains and/or political life.The major external validation of the bipolar status of depressions in associationwith hyperthymic temperament is familial bipolarity comparable to that of bipolarII patients (Cassano et al., 1992).The criteria of bipolar depressive mixed states according to Akiskal and Pintoare given in Table 1.7:Recurrent brief depression, as described by Jules Angst (1988), recurrent briefhypomania (Angst, 1992), and recurrent brief anxiety (Angst and Wicki, 1992), sharean ultrarapid-cycling pattern of mood symptoms according to the findings of Angstet al. (see Chapter 5). The authors point out that the example of recurrentbrief depression demonstrates that severe measures of mood disorders should not