ECT in mixed affective states: a case series.

There is limited information regarding the effectiveness of electroconvulsive therapy (ECT) as a treatment for patients in a mixed affective state. The authors report their experience using this treatment in medication-resistant patients meeting Research Diagnostic Criteria (RDC) for both mania and major depression. Clinical and response characteristics of these patients are described. Forty-one consecutively admitted patients meeting the RDC for mania received pharmacotherapy. Eight patients failing to respond to pharmacotherapy were referred for ECT, and seven consented. All met RDC for both mania and major depressive disorder. All patients receiving ECT remitted. The patient who did not accept ECT did not improve and ultimately needed transfer to a state hospital for longer term care. Mixed manic-depressive states are responsive to ECT, even in medication-refractory patients.

Phenomenology of mania: evidence for distinct depressed, dysphoric, and euphoric presentations.

OBJECTIVE: A substantial number of manic episodes include conspicuous depressive symptoms. Manic episodes have been clinically classified a posteriori using preset criteria. The aim of this study was to investigate the possibility that there might be a natural division of manic episodes into clinical types. METHOD: One hundred and five inpatients met Research Diagnostic Criteria and DSM-III-R criteria for manic episodes and were rated before institution of pharmacological treatment. The authors conducted a factor analysis of 37 behavior rating items from the Schedule for Affective Disorders and Schizophrenia. The resulting factors were used as independent variables in a cluster analysis of the patients. RESULTS: This analysis revealed four factors corresponding to manic activation, depressed state, sleep disturbance, and irritability/paranoia. Cluster analysis separated the patients into two groups. One included patients with major depressive disorder and mania. Blind, a priori clinical classification into classic and mixed mania (mania plus depression) showed that all of the patients in the depressed cluster, and about 40% of those in the nondepressed cluster, were in a mixed state according to clinical criteria. Comparison of the clinically mixed and nonmixed patients in the nondepressed cluster revealed that the mixed patients in that cluster had higher scores for items related to anger, worry, dysphoria, and irritability. CONCLUSIONS: These data suggest that manic episodes can be naturalistically classified as classic (predominately euphoric), dysphoric, or depressed.

Suicidality, panic disorder and psychosis in bipolar depression, depressive-mania and pure-mania.

This study was undertaken to assess links between suicidality, panic disorder, psychosis, bipolar depression, depressive-mania and pure-mania. The subjects are a consecutive series of 129 persons with bipolar disorder who were admitted to a university teaching hospital; 53 had bipolar depression, 32 had depressive-mania and 44 had pure-mania. They met the Research Diagnostic Criteria (RDC) for major depressive disorder (bipolar depression), primary mania (pure-mania) or both disorders (depressive-mania) at entry into the study. Suicidality, intra-episode panic disorder (IEPD) and psychotic features were ascertained using structured interviews. Sources of data included a routine clinical interview, serial clinical assessments, the Schedule for Affective Disorders and Schizophrenia (SADS), the Structured Clinical Interview for DSM-III-R and reviews of charts. Multivariate logistic regression analysis was used to determine the strength of the relationships between suicidality, IEPD, psychotic features and the phase of illness. The rates of suicidality (79.3%, 56.3% and 2.3%), IEPD (62.3%, 62.5% and 2.3%) and psychotic features (52.8%, 96.9% and 88.6%) differed significantly between the groups with bipolar depression, depressive-mania and pure-mania. Subjects with bipolar depression and depressive-mania resembled one another with respect to the severity, but not rate of suicidality. They had identical rates of IEPD. Subjects with bipolar depression had a higher probability of being suicidal and a lower probability of being psychotic than persons with either subtype of mania. Pure-mania was distinguished by low rates of suicidality and IEPD. The authors describe directions for prospective studies of the relationships between phase of illness and phenomena in groups of bipolar persons.

Suicidality in patients with pure and depressive mania.

OBJECTIVE: A previous comprehensive literature review indicated that suicide accounted for 18.9% of the deaths of 9,389 individuals with manic-depressive illness. The literature associates these deaths with the depressed phase of the disease. This study was designed to determine the rate and severity of suicidality among patients with pure and depressive mania. METHOD: The patients were 93 persons who met the Research Diagnostic Criteria (RDC) for bipolar I disorder (N = 75) or schizoaffective disorder (N = 18). All met the RDC for primary mania and the DSM-III-R criteria for bipolar disorder, manic or mixed. Patients with depressive mania met the RDC for mania and major depressive disorder concurrently. Severity of current suicidality was measured by using the Schedule for Affective Disorders and Schizophrenia suicide subscale. Differences in the mean suicidality scores between any two groups were assessed with the Kruskal-Wallis test. Relationships of age, gender, type of affective illness (bipolar I versus schizoaffective disorder), psychosis, race, and mania subtype to suicidality were assessed by using multivariate logistic regression analysis. RESULTS: One (2.0%) of the 49 patients with pure mania was suicidal. In contrast, 24 (54.5%) of the 44 patients with depressive mania were suicidal. This difference was highly significant. Gender and psychosis were not related to suicidality. African-Americans were less likely to be suicidal than Caucasians. Subtype of mania had the strongest relationship to suicidality. CONCLUSIONS: A subgroup of manic patients are severely suicidal. Presentation in the manic state is an indication for careful assessment of depressive symptoms and suicidality.

Depressive mania associated with nonresponse to antimanic agents.

Of 39 patients consecutively admitted for the treatment of primary mania, 21 (53.8%) simultaneously met the Research Diagnostic Criteria for major depressive disorder ("mixed" or "depressive" mania). Only nine (42.9%) of the 21 patients with depressive mania responded to antimanic agents. In contrast, 16 (88.9%) of the 18 patients with pure mania responded to these drugs. This finding is consistent with previous reports suggesting that the mixed state is a virulent form of mania.

The manic syndrome: factors which may predict a patient's response to lithium, carbamazepine and valproate.

Studies suggest that 80% to 90% of all patients in the manic state respond to lithium provided that they are relatively free of dysphoria ("pure mania"). In contrast, less than 40% of individuals in the manic state who cycle rapidly or are substantially dysphoric ("dysphoric mania") respond to lithium. These patients appear to be more responsive to carbamazepine and valproate. The authors conclude that carbamazepine and valproate are the drugs of choice if one desires to treat a rapidly cycling individual or patient with dysphoric mania with just one agent. However, they emphasize that a prospective study designed to identify the predictors of response of primary mania to lithium, carbamazepine and valproate is required. Studies assessing the relative value of lithium, carbamazepine or valproate as prophylactic agents in the care of patients with specific subtypes of mania are also needed. These studies would address the most important issues confronting researchers interested in the drug treatment of mania.