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

37 Beyond major depression and euphoric maniaLessons from the past and options for the futureObviously, bipolar disorders belong to a great family, including members withvery strong family similarities, but also individual characteristics, separating themfrom other members and characterizing them in an unchangeable way. But thebasic characteristics remain common for all members. This is not a new concept,but one that is 2000 years old, originated by the father of bipolar disorders –Aretaeus of Cappadocia. We agree with what Aretaeus wrote 2000 years ago:‘‘tro/poi ei) /desi/ men mu/rioi, ge/nei de/ mou=no ei( =j’’: ‘‘There are many different phenomenologicaltypes of the illness, but they all belong to one and the same family.’’But, nevertheless, we still need definitions and concepts with compellingvalidity. As Sachs and Graves point out in this book (see Chapter 17),The psychiatric literature includes relatively few adequately powered and controlled double-blindclinical trials reporting results for bipolar disorders. The majority of these randomized clinicaltrials report results for treatment of acute mania in hospitalized bipolar I (BP-I) patients. Themajority of bipolar patients are, however, not BP-I, and manic states are relatively infrequent. Whyare there so few published controlled treatment studies dealing with common clinical problemslike rapid cycling, mixed episodes, and atypical bipolar disorder? (see Chapter 17).The authors give the answer:‘‘The first consideration is the conceptual dissimilarity of the terms rapid cycling, mixedepisodes, and atypical bipolar disorder. These terms correspond to three distinct organizationallevels used in the DSM-IV mood disorder nosology and represent the concepts of coursespecifier, acute episode, and subtype of bipolar (American Psychiatric Association, 1994).Study designs for each require attention to sample selection, outcome measures and an analysisplan matched to the appropriate level in the organizational hierarchy of the DSM-IV mooddisorder classification (see Chapter 17).The purpose of this book is to establish the evidence that can enhance the validityof our definitions and nosological allocations, which in turn might be expected toenhance our clinical care and lead to more focused research questions.REFERENCESAkiskal, H. S. (1981). Subaffective disorders: dysthymic, cyclothymic and bipolar II disorders inthe ‘‘border-line’’ realm. Clin. North Am., 4, 25–46.Akiskal, H. S. (1992). The mixed states of bipolar I, II, III. Clin. Neuropsychopharm., 15 (suppl.1a), 632–3.Akiskal, H. S. (1997). Overview of chronic depressions and their clinical management. InDysthymia and the Spectrum of Chronic Depressions, ed. H. S. Akiskal and G. B. Cassano,pp. 1–34. New York: Guilford Press.