This activity is intended for psychiatrists and primary care physicians who diagnose and treat depression.
The goal of this activity is to describe the current conceptualization of the biology of bipolar depression and relate its presentation to the need for early and accurate diagnosis.
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CME Released: 3/27/2013
Valid for credit through: 3/27/2014, 11:59 PM EST
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One of the critical observations that been made not only by clinicians who are busy in practice, but also by many academic observers who are reporting on the phenomenology of bipolar disorder is the notion of subsyndromal symptomatology. There's no question that bipolar disorder is composed of many phenotypic variants, with mania being the most severe mood excursion. The lion’s share, however, of individuals who have bipolar disorder do not in fact present with severe mania.[1] They're often presenting with an admixture of subsyndromal depressive symptoms as well as hypomanic symptoms. In fact, longitudinally the most common presentation is this composite of depressive and hypomanic symptoms, which often is mislabeled as anxious depression or agitated depression; in many cases, there are also personality disorder and other psychiatric conditions. So I think this requires attentiveness to not only the symptom structure of bipolar, but also the additional observation that this really represents the longitudinal picture of this illness over time.
It's important to emphasize that there are definitions for mania and depression, hypomania, and not otherwise specified (NOS) that exist in the DSM-IV-TR, and as clinicians we need to have fidelity to what is presented therein. What we know from clinical experience is that subsyndromal depressive symptoms with hypomanic symptoms are the modal presentation, often manifesting as anxiety, irritability, racing thoughts, or agitation. This mixed-type presentation, what DSM-5 might refer to as the mixed specifier, is the most common presentation.
We should also recognize that patients with bipolar disorder have psychiatric as well as medical comorbidity. Often a comorbidity can blur the diagnosis of bipolar disorder, and in many cases it may be part of bipolar. The best example for me is anxiety. I've often found it very difficult to know with certainly whether the patient's clinically significant anxiety symptoms are part of the bipolar illness, which in many cases it is, or whether they have an anxiety disorder. It’s important for us to refine what bipolar disorder is, cognizant of the very fact that these patients often have comorbidities, 75% or more do,[10] with anxiety disorders being the most common comorbid condition. And we need to be aware of these other co-occurring or comorbid symptoms.
This transcript has been edited for style and clarity.