The bipolar spectrum: do we need a single algorithm for affective disorders?

Key words: bipolar disorder-unipolar depression – diagnosis – treatment – guidelines-suicidality Increasing understanding of the bipolar spectrum of disorders has led to an increasing integration of concepts regarding the aetiology and treatment of affective disorders. Thus, for example, we now understand that an illness, previously believed to be recurrent depressive disorder, may develop over time into a bipolar illness, and bipolar II illnesses may develop into bipolar I It has also been suggested that there may be a continuum between Bipolar Disorder and the mood lability of Borderline Personality disorder (Benazzi et al. 2004, Benazzi et al. 2005). Agitated depression may in fact be a mixed affective state, and injudicious use of powerful antidepressants in patients with undiagnosed bipolar disorder may lead to the development of mixed states or rapid cycling illness, as well as a complete switch from depression to mania (Akiskal et al. 2005). Mixed states and rapid cycling states are linked with increased suicidality (Akiskal et al. 2005). Meanwhile bipolar disorder, especially bipolar II disorder, remains a condition which is underdiagnosed and often inappropriately treated (Morselli et al. 2002, Tavormina et al. 2007, Tavormina et al. 2007, Tavormina et al. 2007). There is evidence that many patients with bipolar illness have a long duration of untreated illness analogous with the Duration of Untreated Psychosis in other psychotic illnesses (Morselli et al. 2002, Agius et al. 2007, Agius et al. 2007). In recent years, there have also been concerns about whether general practitioners do effectively diagnose and effectively treat unipolar depression (Donaghue et al. 1996). Unfortunately, NICE guidelines are separate for Unipolar Depression and Bipolar Illness; those for Unipolar illness advocate a 'stepped care' model, centred round primary care, while bipolar guidelines warn against injudicious use of antidepressants and the use of mood stabilisers to prevent 'switching'to mania (NICE 2004, NICE 2006). Primary care physicians are not warned to take a full longitudinal history in depressed patients, to identify bipolar illness, nor are they trained to use mood stabilisers in patients with bipolar II disorder, and in the risks of injudicious use of antidepressants. In practice, early Bipolar disorder will be identified and treated if Primary Care Doctors are effective in identifying and treating early cases of depression or bipolar disorder which present to them (Paykel et al. 1992). We would suggest that care should be taken that, each patient who presents with major depression, both in primary …