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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 ruminations, 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 evaluated 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 Medicine, Rochester, MN. Address reprint requests 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

n engl j med 364;1

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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.

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Texto traducido

Prctica clnica Trastorno bipolar Una perspectiva sobre la depresin

Mark A. Frye, M.D.
Este artculo comienza con la descripcin de un caso mdico que destaca un problema clnico comn. Se presentan pruebas que sostienen varias estrategias, seguidas de una revisin de pautas formales, cuando existen. El artculo finaliza con las recomendaciones clnicas del autor. Mujer de 26 aos de edad, ejecutiva, acude a consulta mdica por presentar una conducta de aislamiento cada invierno, conducta que comenz cuando la paciente cursaba el bachillerato. Sus sntomas actuales incluyen sueo excesivo, aumento de 9 kg (20 lb) de peso asociado a un incremento en la ingesta de dulces y consumo excesivo de alcohol, anhedonia, falta de motivacin, rumiaciones mentales y disminucin en la productividad laboral. La paciente informa que en la universidad present periodos de numerosas semanas en las cuales tena falta sueo asociadas a cambios de nimo, energa y libido. Durante el ltimo episodio, sobrepas su lmite en la 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, una enfermedad mdica con importante morbilidad y mortalidad, se caracteriza por episodios recurrentes de mana, hipomana y depresin mayor. Una de las caractersticas principales del trastorno bipolar es al menos un episodio de mana (trastorno bipolar tipo I) o de hipomana (trastorno bipolar tipo II) (Tabla N. 1). El grado ms grave de temperamento elevado y la discapacidad funcional asociada distinguen la mana bipolar (caracterizado por presentar psicosis, necesidad urgente de cuidado, hospitalizacin o notable deterioro) de la hipomana bipolar. A diferencia de los pacientes que presentan mana, los pacientes hipomaniacos no buscan ayuda mdica con frecuencia, a menos que ya se les haya hecho un diagnostico de trastorno bipolar y exista inquietud con respecto al progreso de la enfermedad, es decir, temor a convertirse en manaco. Aunque el trmino anterior enfermedad maniaco-depresiva implicaba un episodio depresivo despus de cada episodio de mana, muchos pacientes presentan uno o ms episodios de depresin mayor antes del primero de mana o hipomana, 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 el trastorno unipolar (tabla 1 y 2), En un estudio estadunidense, la tasa de prevalencia de vida del trastorno bipolar fue de 4,5% (1,0 % de trastorno bipolar tipo I; 1,1% de trastorno bipolar tipo II y 2,4% de sntomas manacos y depresivos que no coincidieron con los criterios de diagnostico de trastorno bipolar tipo I o II). El trastorno bipolar est asociado a muerte prematura y se encuentra entre las causas principales de discapacidad en personas de pases desarrollados con edades comprendidas entre 15 y 44 aos de edad. La tasa de suicidio es de un 5% aproximadamente en pacientes que nunca han sido hospitalizados pero puede alcanzar la alta cantidad de 25% al principio de la enfermedad. La enfermedad es frecuentemente asociada con otras condiciones coexistentes, mayormente a trastornos de ansiedad y trastornos por el consumo de sustancias. Estos trastornos se asocian con un riesgo mayor de ideacin suicida y cambios de nimo, que van de la depresin a la mana.
N ENGL J MED 364;1 NEJM.ORG JANUARY 6, 2011 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.

Del Departamento de Psiquiatra y Psicologa, Mayo Clinic College of Medicine, Rochester, MN. Direccin del destinatario al Dr. Frye en el Departamento de Psiquiatra, Mayo Clinic, 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.