The clinical diagnosis of bipolar depression

Abstract

This chapter overviews considerations as to the nature of bipolar depression, an issue of some importance because of potential treatment implications. Representative studies indicate that those with a bipolar I disorder (BD-I) are somewhat likely to experience psychotic depression during depressive episodes, while for the remainder, a melancholic depressive state is most likely to be experienced. In contrast, for those with a bipolar II disorder (BD-II), episodes of psychotic depression are extremely rare, and most are more likely to experience melancholic depressive episodes. For both BD subtypes, ‘bipolar depression’ is rarely non-melancholic in nature, although as non-melancholic depressive episodes can be experienced by any individual as a consequence of life stressors, those with BD are also likely to acknowledge such episodes as well. Identification of the bipolar depressive subtype is therefore best addressed in relation to the individual’s prototypic episodes. The high rates of nonpsychotic and psychotic melancholic depression in those with BD invite consideration as to whether such episodes differ from similar states experienced by those with equivalent unipolar states. Several studies indicate that certain symptoms, such as the ‘atypical features’ of hypersomnia and hyperphagia, may be more frequent in bipolar than unipolar melancholia, but the general conclusion is more one of similarity than of differences in symptom patterns. As bipolar depression is principally of the ‘melancholic’ type, clinical features weighting a diagnosis of melancholia are considered in some detail. Finally, several management nuances in managing bipolar depression are briefly noted.