The

new england journal of medicine

OR IGINAL

clinical practice

Bipolar Disorder A Focus on Depression

Mark A. Frye, M.D.
This Journal feature begins with a case vignette highlighting a common clinical problem. Evidence supporting various strategies is then presented, followed by a review of formal guidelines, when they exist. The article ends with the author's clinical recommendations.

A 26-year-old businesswoman seeks evaluation for a pattern of "hibernating away" each winter; this pattern began when she was in high school. Her current symptoms include excessive sleeping, a 20-lb (9-kg) weight gain related to an increased intake of sweets and excessive alcohol use, anhedonia, lack of motivation, negative rumina- tions, and decreased productivity at work. She reports a history of several-week periods in college when she had less need for sleep, with associated increases in mood, energy, and libido. During the last episode, she exceeded her credit-card limit and was eval- uated at an emergency department for alcohol intoxication. How should she be evaluated and treated?

T h e C l i n ic a l Pr obl e m
Bipolar disorder, a medical illness with substantial morbidity and mortality, is characterized by episodic recurrent mania or hypomania and major depression.1 The hallmark of bipolar disorder is at least one episode of mania (bipolar I disorder) or hypomania (bipolar II disorder) (Table 1).2 The greater severity of the elevated mood and the associated functional disability distinguish bipolar I mania (which is characterized by psychosis, the need for urgent care or hospitalization, or marked impairment) from bipolar II hypomania. In contrast to patients with mania, patients with hypomania infrequently seek evaluation unless a bipolar diagnosis is already established and there is concern regarding progression of the illness (i.e., becoming manic). Whereas the older term "manic-depressive illness" implied a depressive episode after each episode of mania, many patients present with one or more episodes of major depression before the first manic or hypomanic episode that defines bipolar disorder. The diagnostic criteria for an episode of major depression in bipolar disorder are the same as the criteria for unipolar major depressive disorder (Tables 1 and 2). In a U.S. study,3 the lifetime prevalence rate of bipolar disorder was 4.5% (1.0% for bipolar I disorder, 1.1% for bipolar II disorder, and 2.4% for manic and depressive symptoms that did not meet all the diagnostic criteria for bipolar I or bipolar II disorder). Bipolar disorder is associated with premature death and is among the leading causes of disability in the developed world in people 15 to 44 years of age. 4 The rate of completed suicide is approximately 5% among patients who have never been hospitalized, but it is as high as 25% early in the course of the illness.5,6 The illness is frequently associated with other coexisting conditions, most commonly anxiety disorders and substance-use disorders.7,8 These disorders are associated with an increased risk of suicidal ideation and of mood switches from depression to mania.9,10 Although the severity of mania is evident, most disability associated with bipolar disorder occurs in the depressive phase. In one study, there were significantly
From the Department of Psychiatry and Psychology, Mayo Clinic College of Medi- cine, Rochester, MN. Address reprint re- quests to Dr. Frye at the Department of Psychiatry, Mayo Clinic, 200 First St. SW, Rochester, MN 55901, or at mfrye@mayo .edu. N Engl J Med 2011;364:51-9.
Copyright 2011 Massachusetts Medical Society.

An audio version of this article is available at NEJM.org

The New England Journal of Medicine Downloaded from nejm.org at SUNY BUFFALO on January 19, 2011. For personal use only. No other uses without permission. Copyright 2011 Massachusetts Medical Society. All rights reser ved.

The

new england journal of medicine

TRADUCCIN

Prctica clnica

Trastorno bipolar. Un enfoque sobre la depresin

Mark A. Frye, M.D. Traducido por Kelly Vizcaino

Este artculo se inicia con la descripcin de un caso mdico que destaca un problema clnico comn. Luego, se presentan pruebas que sustentan varias estrategias, seguidas de una recopilacin de criterios formales existentes. El artculo concluye con las recomendaciones clnicas del autor.

Empresaria de 26 aos acude a consulta por presentar una conducta de aislamiento cada invierno, conducta que comenz en bachillerato. Sus sntomas actuales incluyen sueo excesivo, aumento de peso de aproximadamente 9kg (20 lb) relacionado con un incremento en el consumo de dulces y excesivo uso de alcohol, anhedonia, prdida de la motivacin, rumiaciones mentales y una disminucin en la productividad laboral. La paciente explica que durante la universidad tuvo periodos de varias semanas donde tena falta de sueo, asociadas a cambios de nimo, energa y libido. Durante el ltimo episodio, excedi el lmite de su tarjeta de crdito y fue evaluada en una sala de emergencias por intoxicacin etlica. Cmo debera ser evaluada y tratada? EL PROBLEMA CLNICO El trastorno bipolar es una enfermedad mdica con un importante porcentaje de morbilidad y mortalidad. Se caracteriza por episodios recurrentes manacos o hipomanacos y depresin mayor. Una de las particularidad del trastorno bipolar es al menos un episodio de mana (trastorno bipolar tipo I) o de hipomana (trastorno bipolar tipo II) (tabla I). El grado mas grave de temperamento elevado as como tambin una discapacidad funcional asociada distinguen la mana bipolar (caracterizada por psicosis, necesidad urgente de atencin, hospitalizacin o una notable discapacidad) de la hipomana bipolar. A diferencia de los que presentan episodios manacos, los pacientes con hipomana rara vez acuden a consulta, a menos que se les haya diagnosticado trastorno bipolar y exista preocupacin con respecto al progreso de la enfermedad, es decir, temor a convertirse en manacos. Mientras que el trmino anterior enfermedad maniaco-depresiva implicaba un episodio depresivo tras el episodio manaco, muchos pacientes presentan uno o ms episodios de depresin mayor antes del primer episodio manaco o hipomanaco, lo que define el trastorno bipolar. Los criterios diagnsticos ante un episodio de depresin mayor en el trastorno bipolar son los mismos criterios empleados para la depresin mayor en trastorno unipolar (tablas 1 y 2.) Un estudio realizado en los Estados Unidos indic que la tasa de prevalencia de vida con respecto al trastorno bipolar fue de 4,5% (1,0% para el trastorno bipolar tipo I, 1,1% para el trastorno bipolar tipo II y 2,4% para sntomas maniacos y depresivos que no coincidieron con los criterios diagnsticos del trastorno bipolar de tipo I y II). El trastorno bipolar est relacionado con la muerte prematura y se encuentra entre las principales causas de discapacidad en pases desarrollados, en personas con edades comprendidas entre 15 y 44 aos. La tasa de suicidios abarca aproximadamente un 5% entre los pacientes que nunca han sido hospitalizados; sin embargo puede llegar a 25% en la etapa inicial de la enfermedad. La enfermedad es frecuentemente asociada con otras condiciones coexistentes, mayormente trastornos de ansiedad y trastornos debido al consumo de sustancias. Estos trastornos estn asociados con un mayor riesgo de ideacin suicida y cambios de nimo, que van desde depresiones hasta episodios manacos.
Del departamento de psiquiatra y psicologa, Mayo Clinique Colege of Medicine, Rochester, MN. Direccin del destinario al Dr. Frye en el departamento de psiquiatra, 200 first St. SW, Rochester, MN 55901, o al mfrye@mayo.edu N Engl J Med 2011; 364:51-9. Copyright 2011 Massachusetts Medical Society.

Existe una versin en audio de este artculo, disponible en NEJM.org

The New England Journal of Medicine Downloaded from nejm.org at SUNY BUFFALO on January 19, 2011. For personal use only. No other uses without permission. Copyright 2011 Massachusetts Medical Society. All rights reserved.