ABSTRACTS - World Psychiatric Association

effects on bipolar non-mixed depression). Fluoxetine/olanzapine combination
stands out, as it has shown similar efficacy in mixed vs. nonmixed
bipolar I depression, in a large controlled study. It is noteworthy
that fluoxetine (it cannot be inferred all selective serotonin reuptake
inhibitors) added to second-generation antipsychotic olanzapine (it
cannot be inferred all second-generation antipsychotics) was effective
for mixed depression, while olanzapine alone was less effective (but
better than placebo).
RS3.2.
BIPOLAR MIXED DEPRESSIONS: CLINICAL
FEATURES AND RELATION WITH SUICIDALITY
Z. Rihmer
Department of Clinical and Theoretical Mental Health,
Semmelweis University, Budapest, Hungary
Mistreatment of mood disorders is one of the main causes of attempted
and completed suicide. Since most mood disorder patients never
commit or attempt suicide, investigating the clinical variables related
to suicide in depression is a priority. A proximate suicide risk factor is
mixed depression (depressive mixed states), i.e., depression plus cooccurring
manic/hypomanic symptoms such as irritability, psychomotor
agitation, talkativeness, and racing/crowded thoughts. The definitions
most commonly used require at least 2 to 3 manic/hypomanic
symptoms (not specific symptoms, such as psychomotor agitation).
Mixed depression is not included in DSM-IV and ICD-10. Its frequency
is higher in bipolar disorders (20 to 70%, depending on several
factors), but it is not uncommon in unipolar depression. Suicide
attempts and suicidal ideation are more frequent in mixed than in
non-mixed (unipolar and bipolar) depression. We have recently found
a much higher frequency of mixed (bipolar and unipolar) depression
in depressed suicide attempters than in depressed non-suicide
attempters. Suicide attempters had mainly a bipolar II mixed depression,
explaining, at least in part, why bipolar II disorder carries the
highest risk of suicidal behaviour among mood disorders. Diagnosing
mixed depression as a possible suicide risk factor has important implications
for suicide prevention, since antidepressant monotherapy
(i.e., unprotected by mood stabilising agents) in a “missed” mixed
depression can worsen its clinical picture by increasing the severity of
manic/hypomanic symptoms. Antidepressant monotherapy in bipolar
depression, but also in unipolar depression (especially with signs of
bipolarity), can also induce the new onset of a mixed depression.
RS3.3.
THE DICHOTOMY WITHIN THE BIPOLAR
SPECTRUM AND ITS RELATIONSHIP WITH MIXED
DEPRESSION
G. Perugi
Department of Psychiatry, University of Pisa, and Institute
of Behavioural Sciences G. De Lisio, Pisa, Italy
The bipolar spectrum includes also many clinical, often recurrent,
states, such as seasonality, high depression recurrence, recurrent irritability,
neuroasthenia, periodical sleep disturbances, episodic obsessive-compulsive
disorder, and social phobia followed by pharmacologically-induced
hypomania. Impulsive behaviors such as selfaggression
or aggression towards others, pathological gambling and
paraphilias may also be bipolar spectrum disorders. Mood reactivity
of cyclothymic temperament and impulsivity might be related, each
characterized by disinhibited thinking and behavior, poor insight,
and marked dysphoric and pleasurable mood changes. Eating disorders,
bulimia nervosa and binge eating disorder could be related to
impulse control disorders. Comorbidity among bipolar spectrum,
anxiety and impulse control disorders represents a complex picture,
susceptible of different pathogenetic interpretations. Probably, the
pathological process underlying bipolar disorders extends beyond
euphoric and depressive mood dimensions, including negative arousal
affective states, such as anxiety, panic, irritability and impulsivity.
Many bipolar spectrum patients, especially when recurrence is high
and inter-episodic periods are not free of affective manifestations,
may meet DSM-IV criteria for personality disorders. This is particularly
true for bipolar patients with cyclothymic temperament, often
misclassified as borderline personality disorder because of their
extreme mood instability and reactivity. Actually, mood lability of
cyclothymic temperament should be considered a core characteristic
of a bipolar subtype characterized by early onset, high comorbidity,
and more problematic lithium response. Cyclothymic temperament
may facilitate the mixture of manic/hypomanic symptoms and
depression (mixed depression). The distinction of bipolar disorders
with/without cyclothymic temperament could be a more sensitive
predictor of outcome, and may enhance clinical practice and research
endeavours.
RS3.4.
TREATMENT OF BIPOLAR MIXED DEPRESSION
WITH ADJUNCTIVE ANTIDEPRESSANTS: HELP
OR HINDRANCE
J. Calabrese, J. Goldberg
Bipolar Disorders Research, Case Western Reserve University,
University Hospitals Case Medical Center, Cleveland, OH; Mount
Sinai School of Medicine, Affective Disorders Research Program,
Silver Hill Hospital, Norwalk, CT, USA
DSM-IV bipolar I “mixed state” requires co-occurrence of full depression
and mania syndromes. However, there is less recognition of the
prognostic relevance, prevalence, and impact of sub-syndromal symptoms
of mania during major depressive episodes (MDE) in bipolar disorders
(mixed depression). Most recent treatment guidelines advise
against using traditional antidepressants in bipolar mixed depression,
despite absence of large-scale, prospective, controlled trials of subjects
with bipolar mixed depression. Longitudinal, naturalistic data
from NIMH Systematic Treatment Enhancement Program for Bipolar
Disorder (STEP-BD) have recently been analyzed to examine adjunctive
antidepressant use in bipolar depressed patients with concurrent
sub-syndromal manic symptoms (mixed depression), and to compare
times until recovery. In 335 subjects treated with mood stabilizers
with or without an antidepressant, adjunctive antidepressant use was
associated with significantly higher mania symptom severity after 3
months of follow-up, and probability of recovery was lower among
patients with higher baseline depression severity. In 1380 MDE subjects
with bipolar I or II disorders, the most common co-occurring
symptoms of mania were distractibility, flight of ideas/racing
thoughts, and psychomotor agitation. Bipolar mixed depression
patients had more prior suicide attempts and rapid cycling, earlier age
at onset, and more frequent bipolar I (vs. II) illness subtype as compared
to those with “pure” depressed bipolar episodes. Emerging data
suggest clinicians should assess all symptoms of depression and mania
in every depressed patient at every visit, and recognize the risk that
antidepressants may exacerbate concurrent mania symptoms without
improving depression symptoms in bipolar mixed depression.
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