According to the DSM-IV, Bipolar disorders are made up of Bipolar I, Bipolar II, Cyclothymia, and Bipolar Not Otherwise Specified.  Roughly, 1% of people will suffer from Bipolar I Disorder, commonly called manic-depression.  It affects men and women equally and is not concentrated in any ethnic group.  Before treatment was available, the average afflicted person suffered four episodes in a 10 year period of time, although for some episodes occur much more frequently.  Most individuals are totally normal between episodes.  Individuals suffering four or more episodes in a one year period are said to be "rapid-cycling."  Psychotic symptoms can sometimes occur, causing Bipolar I to be confused with schizophrenia. 

To be diagnosed as suffering from Bipolar I Disorder, the patient must have had at least one Manic Episode.  A Manic Episode consists of at least one week or hospitalized with an abnormal and persistently elevated, expansive, or irritable mood.  During this period, the patient must have three or more of the following (four if the mood is only irritable): 1) inflated self-esteem or grandiosity; 2) decreased need for sleep; 3) more talkative or pressure of speech; 4) flight of ideas or feeling one's thoughts are racing; 5) easily distracted; 6) increased goal-directed activity or psychomotor agitation; and 7) excessive involvement in pleasurable activities (unrestrained shopping sprees, sexual indiscretions, foolish business investments, sudden and excessive traveling).  The mood has to be severe enough to cause a marked impairment in occupational or social functioning or have psychotic features.  Finally, the mood cannot be caused by substance abuse or medication or a medical condition.  The manic episode may also be a mixed episode where it also contains enough depressive symptoms during the week or more to qualify as a Major Depressive Episode.  Of people with Major Depressive Disorder, 10-15% will eventually develop Bipolar I Disorder.  There frequently is an increase in depressive and bipolar disorders in family members providing strong evidence of a genetic link.

Individuals with both Bipolar I and Bipolar II may suffer one or more Hypomanic Episodes.  A Hypomanic Episode consists of a distinct and unusual period of persistently elevated, expansive, or irritable mood of at least 4 days with three or more of the same symptoms listed above for a Manic Episode.  The mood disturbance has to be noticeable to others, but not severe enough to cause a marked impairment in social or occupational functioning or require hospitalization or have psychotic features.  The episode cannot have been caused by substance abuse or medication or a medical condition.  Individuals who have had a Hypomanic Episode may not consider the episode as part of an illness but close friends or family will usually be troubled by the episode.  

For a diagnosis of Bipolar II Disorder, there must have been at lest one Major Depressive Episode and at least one Hypomanic Episode, but never a Manic or Mixed (Manic and Depressive) Episode.  The mood symptoms cannot be better explained by a diagnosis of a Schizoaffective Disorder or Schizophrenia. 

A Cyclothymic Disorder is an initial period of two years (one year for a child or teen) with hypomanic and depressive periods, but never severely ill enough to be diagnosed as suffering from a Manic or Major Depressive Episode.  Also, the person cannot have had normal periods lasting over two months during the two years.  Of course, the symptoms may not not have been caused by substance abuse, medication, or medical illness and must cause a clinically significant distress or impairment in functioning.

Individuals with bipolar features that do not fully meet any of the above requirements are diagnosed as having Bipolar Disorder Not Otherwise Specified.  They symptoms may not be lasting long enough, or they may only be having recurrent hypomanic episodes, or it may be unclear if the cause might be substance abuse, medication, or a medical illness.

Mood disorders due to substance abuse or medication is a Substance-Induced Mood Disorder. It may be from alcohol, amphetamines, cocaine, hallucinogens, inhalants, opioids, phencyclidine, marijuana, sedatives, tobacco or medications. 

There is a major movement to expand the Bipolar diagnosis and to rediagnose many patients with Major Depressive Disorders as Bipolar II.  This is at least in part due to the influence of pharmaceutical companies since many anti-depressants are losing their patent protection, while many anti-manic treatments are still covered by patent (e.g. J Affect Disord. 2004 Nov 1;82(3):373-83).  As you may have guessed, I am uncomfortable with the expansion of Bipolar Spectrum Disorders and have not seen good scientific evidence to support it.  There are relatively few reports of anti-depressant induced mania in the huge number of DB PC studies of anti-depressant treatment for Major Depressive Disorders. 

"What is a Bipolar Disorder?" Germans Guess the Melting of the Polar Ice Caps: In a telephone survey of 1006 randomly selected Germans, out of four options given, respondents were asked to select the one they considered to be correct. Most of the respondents (61%) believed that bipolar disorder is just another term for the melting of the polar ice caps, only 4.6 % associated it with mental illness. Results of a representative survey of the German population. Angermeyer MC et al. Universitat Leipzig, ermany. . Psychiatr Prax. 2005 Sep;32(6):289-91. Ed: I have repeatedly wished the ivory tower geniuses never changed from manic-depression.

Everybody's Bipolar: It Helps Make Money for the Drug Companies: In a report from San Diego and Italy, 563 consecutive private outpatients with a DSM-IV-diagnosed major depressive episode (MDE) were evaluated using a modified SCID-CV, a duration of hypomania >/=2 days (rather than the 4-day floor cutoff recommended), did not follow the SCID-CV's stem (mood) skip-out instruction, focused more on past history of overactive behavior rather than mood change, and assessed hypomanic features both outside and during index MDE. Bipolar-II was diagnosed in 57% of patients! Compared with MDD, BPII had a significantly earlier index age and age at onset of first MDE and higher rates of atypical features, depressive recurrences, hypomanic symptoms during MDE, trait mood lability, and bipolar family history (p = .0000 for all variables). Optimizing the Detection of Bipolar II Disorder in Outpatient Private Practice: Toward a Systematization of Clinical Diagnostic Wisdom. Akiskal HS, Benazzi F.  University of California, San Diego, and National Health Service, Forli, Italy. J Clin Psychiatry. 2005 Jul;66(7):914-921. Ed: I personally don't agree with the trend of diagnosing the majority of depressed patients as bipolar.  What it does is deprive many patients of vigorous treatment for depression as many psychiatrists obsess about avoiding mania.  It also means that many patients will be also given the expensive and patented divalproex (Depakote-ER), lamotrigine (Lamictal), or an atypical anti-psychotic (Zyprexa, Seroquel, Risperdal) and that for most of them this may be unnecessary. Even true bipolar-I's suffer from depression three times as long as they have mania and the depression is much more painful. Many psychiatrists undertreat the depression.  Bipolars are much more likely to kill themselves while depressed than while manic.  While I have a high respect for Dr. Akiskal, this time I think he's wrong. 

Large Percentage of Depressed Teens Called Bipolar: In a study of 247 Hispanic teens presenting with major depressive disorders, 41% were given the diagnosis of bipolar I or II disorder, depressed. Of these bipolars, 58% were boys. The mean age was 14 with 82% in a mixed state. Of those in mixed states, 56% were boys, 55% purportly had psychotic features, 12% had family histories of just major depressive disorder while 32% had family histories of bipolar disorder, 67% had suicidal ideation and 51% had a history of a physically self-destructive act such as wrist cutting or overdoses. Mixed States: the most common outpatient presentation of bipolar depressed adolescents? Dilsaver SC, et al. Rio Grande City, Tex., USA. Psychopathology. 2005 Sep-Oct;38(5):268-72.

Women Bipolars More Type II, Thyroid, Bulimia, and PTSD Than Men: Data from the first 500 patients in the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) shows that women had higher rates of BPII (15.3% M vs. 29.0% F), comorbid thyroid disease (5.7% M versus 26.9% F), bulimia (1.5% M versus 11.6% F), post-traumatic stress disorder (10.6% M versus 20.9% F) and men were more likely to have a history of legal problems (36% M versus 17.5% F)(all p < 0.01). Women and men had equal rates of history of lifetime rapid cycling and depressive episodes. Gender differences in bipolar disorder: retrospective data from the first 500 STEP-BD participants. Baldassano CF, et al. University of Pennsylvania, Philadelphia, PA, USA. Bipolar Disord. 2005 Oct;7(5):465-70.

Bipolar Relapse in Adult Linked to Adderall: An adult who had been 13 years in remission from a bipolar disorder and off medication was given Adderall for symptoms which were diagnosed as adult ADHD. The patient suffered a severe and disabling relapse of her Bipolar Disorder which has continued despite extensive treatment. (Reported to me via email 11/26/04).  The manufacturer of Adderall in the PDR warn of psychotic episodes and depressions being caused by Adderall, but bipolar relapse is not listed as of 2004.  I encouraged the writer to report the side-effect to the FDA.

Hypomanic Episode from Anti-Depressant Probably Occurs Only in Bipolars: 89% of studies of antidepressants in major depressive disorder patients reported no cases of treatment-induced hypomania. No instances of treatment-induced hypomania were reported in three large studies of patients with chronic forms of depression. The authors conclude that depressed patients who experience antidepressant-associated hypomania are truly bipolar. A review of antidepressant-induced hypomania in major depression: suggestions for DSM-V. Chun BJ, Dunner DL. University of Washington. Bipolar Disord. 2004 Feb;6(1):32-42

Mixed Depression and Hypomania Almost Entirely in Women: Mixed hypomania was defined at a given visit as a Young Mania Rating Scale score of 12 or higher and an Inventory of Depressive Symptomatology-Clinician-Rated Version score of 15 or higher. In 908 patients, 14,328 visits over 7 years found patients with bipolar I were significantly more likely to experience hypomania than those with bipolar II. Of all 1,044 visits by patients with hypomanic symptoms, 57% met criteria for mixed hypomania. The likelihood of depression was much greater for women during hypomania (P<.001) except at the most severe levels of hypomania or mania. When eliminating irritability and agitation factors, present in both depression and hypomania definitions, a mixed state effect persisted for women (P<.001) but not for men (P = .95). Mixed Hypomania in 908 Patients With Bipolar Disorder Evaluated Prospectively in the Stanley Foundation Bipolar Treatment Network: A Sex-Specific Phenomenon. Suppes T, et al. University of Texas Southwestern. Arch Gen Psychiatry. 2005 Oct;62(10):1089-1096.

Thomas E. Radecki, M.D., J.D.

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