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15 - The treatment of bipolar mixed states

Published online by Cambridge University Press:  10 August 2009

By
John Cookson  and
Saad Ghalib
Edited by
Andreas Marneros  and
Frederick Goodwin
John Cookson
Affiliation:
Royal London Hospital London UK
Saad Ghalib
Affiliation:
Royal London Hospital London UK
Andreas Marneros
Affiliation:
Martin Luther-Universität Halle-Wittenburg, Germany
Frederick Goodwin
Affiliation:
George Washington University, Washington DC
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Summary

Mixed states pose particular problems in their classification, diagnosis, and treatment, because they may be conceptualized as arising in a variety of ways (Table 15.1).

Mixture of elements (mood, activity, thinking)

Mixed states may represent a mixture of different elements of depressed and manic conditions. For Kraepelin, the core pathology of clinical depression was expressed in separate areas of functioning: lowering of mood, and slowed or retarded mental and physical activity. The opposite applied in mania: euphoria, flight of ideas, and hyperactivity. Kraepelin (1913) recognized six mixed states, the most common being depressive or anxious mania, excited depression, and depression with flight of ideas. Others were manic stupor, mania with poverty of thought, and inhibited mania (without flight of ideas). Other combinations were theoretically possible but rarely recognized in practice. Kraepelin distinguished “autonomous” mixed episodes from those occurring during transitions from one mood phase to another (see transition state during a cycle, below) and thought them to be “the most unfavourable form of manic-depressive insanity.”

Severe stage of mania

The mixed state may represent a qualitatively distinct presentation of mania, with classical manic symptoms accompanied by marked anxiety, depression, or anger. These symptoms tend to emerge in more severe stages of the illness and then to be correlated in severity; thus Carlson and Goodwin (1973) described three stages of mania through which an episode may develop, corresponding to mild, moderate, and severe levels of symptoms.

Keywords

antidepressantsbipolar disorderdepressionDMIlamotriginemixed statesdysphoric maniahaloperidolrapid cycling bipolar patients
Type
Chapter
Information
Bipolar Disorders
Mixed States, Rapid Cycling and Atypical Forms
 , pp. 324 - 352
Publisher: Cambridge University Press
Print publication year: 2005

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References

Abraham, K. (1949). A Short Study of the Development of the Libido, Viewed in the Light of Mental Disorders: Mania. Selected Papers of Karl Abraham, translated by. D. Bryan and A. Strachey pp. 470–5. London: Hogarth.
Akiskal, H. S. (2002). Classification, diagnosis and boundaries of bipolar disorders: a review. In Bipolar Disorder, ed. Maj, M., Akiskal, H. S., Lopez-Ibor, J. J., and Sartorius, N., pp. 1–52. WPA series: Evidence and Experience in Psychiatry. Chichester, UK: John Wiley.
Akiskal, H. S., and Akiskal, K. (1992). Cyclothymic, hyperthymic and depressive temperaments as subaffective variants of mood disorders. In Review of Psychiatry, vol. 11, ed. Tasman, A. and Ribas, M. B., pp. 43–62. Washington, DC: American Psychiatric Press.
Akiskal, H. S. and Mallya, G. (1987). Criteria for the “soft” bipolar spectrum: treatment implication. Psychopharmacol. Bull., 23, 68–73Google Scholar
Akiskal, H. S., Hantouche, E. G., Bourgeois, M., et al. (1998a). Gender, temperament, and the clinical picture in dysphoric mixed mania: findings from a French national study (EPIMAN). J. Affec. Disord., 50, 175–86.Google Scholar
Akiskal, H. S., Placidi, G. F., Signoretta, S., et al. (1998b). TEMPS-I: delineating the most discriminant traits of cyclothymic, depressive, irritable and hyperthymic temperaments in a nonpatient population. J. Affect. Disord., 51, 7–19.Google Scholar
Akiskal, H. S., Bourgeois, M. L., Angst, J., et al. (2000). Re-evaluating the prevalence of and diagnostic composition within the broad clinical spectrum of bipolar disorders. J. Affect. Disord., 59, S5–30.Google Scholar
Altshuler, L. L., Post, R. M., Leverich, G. S., et al. (1995). Antidepressant induced mania and cycle acceleration: a controversy revisited. Am. J. Psychiatry, 152, 1130–8.Google Scholar
Altshuler, L., Suppes, T., Black, D., et al. (2003). Impact of antidepressant discontinuation after acute bipolar depression remission on rates of depressive relapse at 1-year follow-up. Am. J. Psychiatry, 160, 1252–62Google Scholar
American Psychiatric Association (1987). Diagnostic and Statistical Manual of Mental Disorders 3rd edn revised. Washington, DC: American Psychiatric Association.
American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders 4th edn (DSM-IV). Washington, DC: American Psychiatric Association.
Angst, J. (1978). The course of affective disorders. II. Typology of bipolar manic-depressive illness. Arch. Psychiatr. Nervenkr., 226, 65–73.Google Scholar
Angst, J. (1985). Switch from depression to mania: a recorded study over decades between 1920 and 1982. Psychopathology, 18, 140–54.Google Scholar
Angst, J. (2000). Temperament and personality types in bipolar patients: a historical review. In Bipolar Disorders: 100 Years After Manic-Depressive Insanity ed. Marneros, A. and Angst, J., pp. 175–99, Dordrecht: Kluwer.
Baillarger, J. (1854). De la folie à double forme. Ann. Med. Psychol. (Paris), 6, 367–91.Google Scholar
Baker, R. W., Tohen, M., Risser, R. C., et al. (2000). Depression during mania: treatment response to olanzapine or placebo. Poster Presentation, Stanley Foundation Conference on Bipolar Disorder, Amsterdam.
Baker, R. W., Brown, E., Akiskal, H. S.et al. (2004). Efficacy of olanzapine combined with valproate or lithium in the treatment of dysphoric mania. Br. J. Psychiatry, 185, 472–8.Google Scholar
Bauer, M. S., Calabrese, J., Dunner, D., et al. (1994a). Multisite data re-analysis of the validity of rapid cycling as a course modifier for bipolar disorder in DSM-IV. Am. J. Psychiatry, 151, 506–15.Google Scholar
Bauer, M. S., Whybrow, P. C., Gyulai, L., Gonnel, J., and Yeh, H. S. (1994b). Testing definitions of dysphoric mania and hypomania: prevalence, clinical characteristics and inter-episode stability. J. Affect. Disord., 32, 201–11.Google Scholar
Beigel, A. and Murphy, D. L. (1971). Assessing clinical characteristics of the manic state. Am. J. Psychiatry, 128, 688–94.Google Scholar
Benazzi, F. (2000). Depressive mixed states: unipolar and bipolar II. Eur. Arch. Psychiatry Clin. Neurosci., 250, 249–53.Google Scholar
Bernadt, M. W. and Murray, R. M. (1986). Psychiatric disorder, drinking and alcoholism. Bri. J. Psychiatry, 148, 393–400.Google Scholar
Bourgeois, M. L. (2002). What is disordered in bipolar disorders? In Bipolar Disorder, ed. Maj, M., Akiskal, H. S., Lopez-Ibor, J. J., and Sartorius, N.. WPA series: Evidence and Experience in Psychiatry, pp. 64–7. Chichester, UK: John Wiley.
Bowden, C., Brugger, A. M., Swann, A. C., et al. (1994). Efficacy of divalproex versus lithium and placebo in the treatment of mania. J. A. M. A., 271, 918–24.Google Scholar
Bowden, C. L., Calabrese, J. R., McElroy, S. L., et al. (2000). A randomised placebo-controlled twelve month trial of divalproex and lithium in the treatment of outpatients with bipolar I disorder. Arch. Gen. Psychiatry, 57, 481–9.Google Scholar
Bowden, C. L., Calabrese, J. R., Sachs, G., et al. (2001). A placebo-controlled 18-month trial of lamotrigine and lithium maintenance treatment in recently manic or hypomanic patients with bipolar I disorder. Arch. Gen. Psychiatry, 60, 392–400.Google Scholar
Bowden, C. L., Ghaemi, N., Gyulai, L., et al. (2002). Lamotrigine delays mood episodes in recently depressed bipolar patients. In: 2002 Annual Meeting New Research Program and Abstracts, p. 81. Washington, DC: American Psychiatric Association.
Braunig, P., Kruger, S., and Cooke, R. G. (2002). Relevance of the catatonic syndrome to the mixed state (abstract). Bipolar Disord., 4 (suppl. 1), 45.Google Scholar
Calabrese, J. R., Woyshville, M. J., Kimmel, S. E., and Rapport, D. J. (1993). Predictors of valproate response in bipolar rapid cycling. J. Clin. Psychopharmacol., 13, 280–3.Google Scholar
Calabrese, J. R., Bowden, C., McElroy, S., et al. (1999a). Spectrum of activity of lamotrigine in treatment-refractory bipolar disorder. Am. J. Psychiatry, 156, 1019–23.Google Scholar
Calabrese, J. R., Bowden, C., and Sachs, G. (1999b). A double-blind placebo-controlled study of lamotrigine monotherapy in outpatients with bipolar I depression. J. Clin. Psychiatry, 60, 79–88.Google Scholar
Calabrese, J. R., Suppes, T., Bowden, C. L., et al. (2000). A double-blind placebo-controlled prophylaxis study of lamotrigine in rapid cycling bipolar disorder. J. Clin. Psychiatry, 61, 841–50.Google Scholar
Calabrese, J. R., Bowden, C., Mee-Lee, D., et al. (2002). Lamotrigine or Lithium in the Maintenance Treatment of Bipolar I Disorder. Philadelphia, PA: American Psychiatric Association.
Cannon, M., Caspi, A., Moffitt, T. E., et al. (2002). Evidence for early-childhood pan-developmental impairment specific to schizophreniform disorder. Arch. Gen. Psychiatry, 59, 449–56.Google Scholar
Carlson, G. A. and Goodwin, F. K. (1973). The stages of mania: a longitudinal analysis of the manic episode. Arch. Gen. Psychiatry, 28, 221–8.Google Scholar
Cassano, G. B. (2002). Towards a unitary framework for mood spectrum: beyond the bipolar–unipolar dichotomy. In Bipolar Disorder, ed. Maj, M., Akiskal, H. S., Lopez-Ibor, J. J., and Sartorius, N., WPA series: Evidence and Experience in Psychiatry, pp. 75–8. Chichester, UK: John Wiley.
Cassano, G. B., Akiskal, H. S., Savino, M., Musetti, L., and Perugi, G. (1992). Proposed subtypes of bipolar II and related disorders: with hypomanic episodes (or cyclothymia) and with hyperthymic temperament. J. Affect. Disord., 26, 127–40.Google Scholar
Chiarello, R. J. and Cole, J. O. (1987). The use of psychostimulants in general psychiatry. Arch. Gen. Psychiatry, 44, 286–95.Google Scholar
Clouston, T. S. (1896). Clinical Lectures on Mental Diseases. London: J. & A. Churchill.
Cookson, J. C. (1985). The neuroendocrinology of mania. J. Affect. Disord., 8, 233–41.Google Scholar
Cookson, J. C. (1997). Lithium: balancing risks and benefits. Br. J. Psychiatry, 171, 120–4.Google Scholar
Cookson, J. C. (2001). Antipsychotics and lithium for bipolar disorder. Br. J. Psychiatry, 178 (suppl. 41), 148–56.Google Scholar
Cookson, J. C., Moult, P. J. A., Wiles, D., et al (1983). The relationship between prolactin levels and clinical ratings in manic patients treated with oral and intravenous test doses of haloperidol. Psychol. Med., 13, 279–85.Google Scholar
Cookson, J. C., Silverstone, T., Williams, S., and Besser, G. M. (1985a). Plasma cortisol levels in mania: associated clinical ratings and changes during treatment with haloperidol. Br. J. Psychiatry, 46, 498–502.Google Scholar
Cookson, J. C., Silverstone, T., Williams, S., et al. (1985b). Plasma corticol levels in mania: associated clinical ratings and change during treatment with haloperidol. Br. J. Psychiatry, 146, 498–502.Google Scholar
Coryell, W., Turvey, C., Endicott, J., et al. (1998). Bipolar I affective disorder: predictors of outcome after 15 years. J. Affect. Disord. 50, 109–16.Google Scholar
Dell'Osso, L., Placidi, G. F., Nassi, R., et al. (1991). The manic depressive mixed state: familial, temperamental and psychopathologic characteristics in 108 female inpatients. Eur. Arch. Pscyhiatry Clin. Neurosci., 240, 234–9.Google Scholar
Dell'Osso, L., Akiskal, H. S., Freer, P., et al. (1993). Psychotic and nonpsychotic bipolar mixed states: comparisons with manic and schizoaffective disorders. Eur. Arch. Psychiatry Clin. Neurosci., 213, 75–81.Google Scholar
Dilsaver, S. C., Chen, Y. W., Swann, A. C., Shoaib, A. M., and Krajewski, K. J. (1994). Suicidality in patients with pure and depressive mania. Am. J. Psychiatry, 151, 1312–15.Google Scholar
Dunner, D. L.Fleiss, J. L., and Fieve, R. R. (1976). The course of development of mania in patients with recurrent depression. Am. J. Psychiatry, 133, 905–8.Google Scholar
Evans, D. L. and Nemeroff, C. B. (1983). The dexamethasone suppression test in mixed bipolar disorder. Am. J. Psychiatry, 140, 615–17.Google Scholar
Faedda, G. L., Baldessarini, R. J., Tohen, M., Strakowski, S. M., and Waternaux, C. (1991). Episode sequence in bipolar disorder and response to lithium treatment. Am. J. Psychiatry, 148, 1237–9.Google Scholar
Falret, J. P. (1854). Mémoire sur la folie circulaire. Bull. Acad. Méd., 19, 382–415.Google Scholar
Freeman, T. W., Clothier, J. L., Pazzaglia, P., Lesem, M. D., and Swann, A. C. (1992). A double-blind comparison of valproate and lithium in the treatment of acute mania. Am. J. Psychiatry, 149, 108–11.Google Scholar
Frye, M., Ketter, T., Kimbrell, T., et al. (2000). A placebo-controlled study of lamotrigine and gabapentin monotherapy in refractory mood disorders. J. Clin. Psychophamacol., 20, 607–14.Google Scholar
Gawin, F. H. and Kleber, H. D. (1986). Abstinence symptomatology and psychiatric diagnosis in cocaine abusers. Arch. Gen. Psychiatry, 43, 107–13.Google Scholar
Geller, B., Craney, J. L., Bolhofner, K., et al. (2001). One-year recovery and relape rates of children with prepubertal and early adolescent bipolar disorder phenotype. Am. J. Psychiatry, 158, 303–5.Google Scholar
Gerner, R. H., Post, R. M., and Bunney, W. E. (1976). A dopaminergic mechanism in mania. Am. J. Psychiatry, 133, 1177–80.Google Scholar
Ghaemi, S. N. and Goodwin, F. K. (1999). Use of atypical antipsychotic agents in bipolar and schizoaffective disorders: review of the empirical literature. J. Clin. Psychopharmacol., 19, 354–61.Google Scholar
Goodnick, P. J. and Meltzer, H. Y. (1984). Treatment of schizoaffective disorders. Schizophr. Bull., 10, 30–48.Google Scholar
Goodwin, F. K. and Jamison, K. R. (1990). Manic-Depressive Illness. Oxford: Oxford University Press.
Goodwin, G., Bowden, C., Calabrese, J. R., et al. (2002). Results of two placebo-controlled 18-month trials of lamotrigine and lithium maintenance in bipolar I disorder. Am. J. Psychiatry Submitted,Google Scholar
Grunze, H., Kasper, S., Goodwin, G., et al. (2003). The World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for the biological treatment of bipolar disorders, part II: treatmeant of mania. World J. Biol. Psychiatry, 4, 5–13.Google Scholar
Harding, T. and Knight, F. (1973). Marijuana-modified mania. Arch. Gen. Psychiatry, 29, 635–7.Google Scholar
Henry, C., Lacoste, J., Bellivier, F., et al. (1999). Temperament in bipolar illness: impact on prognosis. J. Affect. Disord., 56, 103–8.Google Scholar
Himmelhoch, J. M., and Garfinkel, M. E. (1986). Sources of lithium resistance in mixed mania. Psychopharmacol. Bull. 22, 613–20.Google Scholar
Himmelhoch, J. M.Mulla, D., Neil, J. F., Detre, T. P., and Kupfer, D. J. (1976). Incidence and significance of mixed affective states in a bipolar population. Arch. Gen. Psychiatry, 33, 1062–6.Google Scholar
Himmelhoch, J. M., Thase, M. E., Mallinger, A. G., and Houck, P. (1991). Tranylcypromine versus imipramine in anergic bipolar depression. Am. J. Psychiatry, 148, 910–16.Google Scholar
Hirschfeld, R. M. A., Bowden, C. L., Gitlin, M. J., et al. (2002). Practice guideline for the treatment of patients with bipolar disorder (revision). Am. J. Psychiatry, 159, 1–50.Google Scholar
Janowsky, D. S., El-Yousef, M. K., and Davis, J. M. (1974). Interpersonal manoeuvers of manic patients. Am. J. Psychiatry, 131, 250–5.Google Scholar
Keck, P. E. Jr., McElroy, S. L., Strakowki, S. M., et al. (1998). 12-month outcome of patients with bipolar disorder following hospitalisation for manic or mixed episode. Am. J. Psychiatry, 155, 646–52.Google Scholar
Keller, M. B., Lavori, P. W., Coryell, W., et al. (1986). Differential outcome of pure manic, mixed/cycling, and pure depressive episodes of patients with bipolar illness. J. A. M. A., 255, 3138–42.Google Scholar
Ketter, T. A., and Calabrese, J. R. (2002). Stabilisation of mood from below versus above baseline in bipolar disorder: a new nomenclature. J. Clin. Psychiatry, 63, 146–51.Google Scholar
Klein, M. (1935). In: Segal, H. (1975). Introduction to the Works of Melanie Klein, ed. Khan, M. M. P.. International Psychoanalytical Library. London: Hogarth Press.
Koukopoulos, A. (2002). Prognosis and manic-depressive cycle. In Bipolar Disorder, ed. Maj, M., Akiskal, H. S., Lopez-Ibor, J. J., and Sartorius, N., WPA series: Evidence and Experience in Psychiatry, pp. 168–71. Chichester, UK: John Wiley.
Koukopoulos, A. and Koukopoulos, A. (1999). Agitated depression as a mixed state and the problem of melancholia. Psychiatry Clin. North Am., 22, 547–64.Google Scholar
Koukopoulos, A., Reginaldi, D., Laddomada, P., et al. (1980). Course of the manic-depressive cycle and changes caused by treatments. Pharmakopsychiatr. Neuropsychopharmakol., 13, 156–67.Google Scholar
Koukopoulos, A., Caliari, B., Tondo, A., et al. (1983). Rapid cyclers, temperament and antidepressants. Compr. Psychiatry, 24, 249–58.Google Scholar
Koukopoulos, A., Faedda, G., Proietti, R., et al. (1992). Un syndrome dépressif mixte. Encephale, 18, 19–21.Google Scholar
Kraepelin, E. (1899). Psychiatrie. Ein Lehrbuch für Studierende und Ärzte, vol. 3. Klinische Psychiatrie, 2nd edn. Leipzig: Barth.
Kraepelin, E. (1913). Psychiatrie, vol. 3. Translated as Dementia Praecox and Paraphienia. Edinburgh: E. & S. Livingstone.
Kraepelin, E. (1921). Manic Depressive Insanity and Paranoia. Edinburgh: E. & S. Livingstone.
Kramlinger, K. G. and Post, R. M. (1996). Ultra-rapid and ultradian cycling in bipolar affective disorder. Br. J. Psychiatry, 168, 314–23.Google Scholar
Krishnan, R. R., Maltbie, A. A., and Davidson, J. R. T. (1983). Abnormal cortisol supression in bipolar patients with simultaneous manic and depressive symptoms. Am. J. Psychiatry, 140, 203–5.Google Scholar
Kukopulos, A. and Reginaldi, D. (1973). Does Lithium prevent depression by suppressing manias?Int. Pharmopsychiatry, 8, 152–8.Google Scholar
Licht, R. W. (2002). Limits of the applicability and generalizability of drug trials in mania. Bipolar Disord., 4 (suppl. 1), 66–8.Google Scholar
Licht, R. W., Gouiaev, G., Vestergard, P., et al. (1997). Generalisability of results from randomised drug trials. Br. J. Psychiatry, 170, 264–7.Google Scholar
Littlejohn, R., Leslie, F., and Cookson, J. (1994). Depot antipsychotics in the prophylaxis of bipolar affective disorder. Br. J. Psychiatry, 165, 827–9.Google Scholar
Lowe, M. R. and Batchelor, D. H. (1990). Lithium and neuroleptics in the management of manic-depressive psychosis. Hum. Psychopharmacol., 5, 267–74.Google Scholar
Mander, A. J. and Loudon, J. B. (1998). Rapid recurrence of mania following abrupt discontinuation of lithium. Lancet, ii, 15–17.Google Scholar
Marneros, A. and Angst, J. (2000). Bipolar disorders: roots and evolution. In Bipolar Disorders: 100 Years After Manic-Depressive Insanity, ed. Marneros, A. and Angst, J., pp. 1–36. Dordrecht: Kluwer.
McElroy, S. L., Freeman, M. P., and Akiskal, H. S. (2000). The mixed bipolar disorders. In: Bipolar Disorders; 100 Years after Manic-Depressive Insanity, ed. Marneros, A. and Angst, J., pp. 63–88. Dordrecht: Kluwer.
McGuffin, P., Reveley, A. and Holland, A. (1982). Identical triplets: non-identical psychosis. Br. J. Psychiatry, 140, 1–6.Google Scholar
Moore, P. B., Shepherd, D., Ecclestone, D. J., et al. (2001). Cerebral white matter lesions in bipolar affective disorder: relationship to outcome. Br. J. Psychiatry, 178, 172–6.Google Scholar
Muller-Oerlinghausen, B., Ahren, B., Grof, E., et al. (1992). The effects of long-term lithium treatment on the mortality of patients with manic-depressive and schizo-affective illness. Acta Psychiatri. Scand., 86, 218–22.Google Scholar
Muller-Oerlinghausen, B., Retzow, A., Henn, F. A., et al. (2000). Valproate as an adjunct to neuroleptic medication for the treatment of acute episodes of mania: a prospective, randomized double-blind, placebo-controlled, multicentre study. European Valproate Mania Study Group. J. Clin. Psychopharmacol., 20, 195–203.Google Scholar
Murphy, D. L. and Beigel, A. (1974). Depression, elation, and lithium carbonate responses in manic patient subgroups. Arch. Gen. Psychiatry, 31, 543–8.Google Scholar
Nilsson, F. M., Kessing, L. V., Sorensren, T. M., Andersen, P. K., and Bolwig, T. G. (2002). The risk of developing depression and mania in patients with dementia. Poster: Third European Stanley Foundation Conference, Freiburg. Bipolar Disord., 4 (suppl. 1), 132.Google Scholar
Okasha, A. (2002). Difficulties in evaluating the economics of bipolar disorder in developing countries. In Bipolar Disorder, ed. Maj, M., Akiskal, H. S., Lopez-Ibor, J. J., and Sartorius, N., pp. 496–8. WPA series: Evidence and Experience in Psychiatry. Chichester, UK: John Wiley.
Peroutka, S. J. and Snyder, S. H. (1980). Relationship of neuroleptic drug effects at brain dopamine, serotonin, alpha-adrenergic, and histamine receptors to clinical potency. Am. J. Psychiatry, 137, 1518–22.Google Scholar
Perugi, G., Akiskal, H. S., Micheli, C., et al. (1997). Clinical subtypes of bipolar mixed states: validating a broader European definition in 143 cases. J. Affect. Disord., 43, 169–80.Google Scholar
Perugi, G., Micheli, C., Akiskal, H. S., et al. (2000). Polarity of the first episode, clinical characteristics, and course of manic depressive illness: a systematic retrospective investigation of 320 bipolar I patients. Comp. Psychiatry, 41, 13–18.Google Scholar
Perugi, G., Maremmani, I., Toni, C., et al. (2001). The contrasting influence of depressive and hyperthymic temperaments on psychometrically derived manic subtypes. Psychiatry Res., 101, 249–58.Google Scholar
Pope, H. G., McElroy, S. L., Keck, P. E., and Hudson, J. I. (1991). Valproate in the treatment of acute mania: a placebo-controlled study. Arch. Gen. Psychiatry, 48, 62–8.Google Scholar
Post, R. N., Lake, C. R., Jimerson, D. R., et al. (1978). Cerebrospinal fluid norepinephrine in affective illness. Am. J. Psychiatry, 135, 907–12.Google Scholar
Post, R. M., Ballenger, J. C., Rey, A. C., and Bunney, W. E. Jr. (1981). Slow and rapid onset of manic episodes: implications for underlying biology. Psychiatry Res., 4, 229–37.Google Scholar
Post, R. M., Uhde, T. W., Roy-Byrne, P. P., and Joffe, R. T. (1987). Correlates of antimanic responses to carbamazepine. Psychiatry Res., 21, 71–83.Google Scholar
Post, R. M., Rubinow, D. R., Uhde, T. W., et al. (1989). Dysphoric mania. Clinical and biological correlates. Arch. Gen. Psychiatry, 46, 353–8.Google Scholar
Prien, R. F., Caffey, E. M., and Klett, C. J. (1972). Comparison of lithium carbonate and chlorpromazine in the treatment of mania. Arch. Gen. Psychiatry, 26, 146–53.Google Scholar
Prien, R. F., Himmelhoch, J. M., and Kupfer, D. J. (1988). Treatment of mixed mania. J. Affect. Disord., 15, 9–15.Google Scholar
Quitkin, F. M., Kane, J., Rifkin, A.et al. (1981). Prophylactic lithium carbonate with and without imipramine for bipolar 1 patient: a double-blind study. Arch. Gen. Psychiatry, 38, 902–7.Google Scholar
Quitkin, F. M., Rabkin, J. G., and Prien, R. F. (1986). Bipolar disorder: are there manic-prone and depressive-prone forms?J. Clin. Psychopharmacol., 6, 167–72.Google Scholar
Rees, L., Butler, P. W. P., Gossling, C., et al. (1970). Adrenergic blockade and the corticosteroid and growth hormone response to methyl-amphetamine. Nature, 228, 565–6.Google Scholar
Reichart, C. G., Nolen, W. A., Wals, M., and Hillegers, M. H. J. (2000). Bipolar disorder in children and adolescents: a clinical reality?Acta Neuropsychiatrica, 12, 132–5.Google Scholar
Rottanburg, D., Robins, A. H., Ben-Arie, O., Teggin, A., and Elk, R. (1982). Cannabis-associated psychosis with manic features. Lancet, ii, 1364–6.Google Scholar
Secunda, S. K., Katz, M. M., Swann, A. C., et al. (1987a). Mania: diagnosis, state measurement and prediction of treatment response. J. Affect. Disord., 8, 113–21.Google Scholar
Secunda, S. K., Swann, A. C., and Katz, M. M. (1987b). Diagnosis and treatment of mixed mania. Am. J. Psychiatry., 144, 96–8.Google Scholar
Shulman, K. I. and Post, F. (1980). Bipolar affective disorder in old age. Br. J. Psychiatry, 136, 26–32.Google Scholar
Shulman, K. I., Schaffer, Y., Levitt, A., and Herrmann, N. (2002). Effects of gender and age on phenomenology and management of bipolar disorder: a review. In Bipolar Disorder, ed. Maj, M., Akiskal, H. S., Lopez-Ibor, J. J., and Sartorius, N., pp. 359–97. WPA series: Evidence and Experience in Psychiatry, Chichester, UK: John Wiley.
Sitaram, N., Gillin, J. C., and Bunney, W. E. (1978). The switch process in manic-depressive illness: circadian variations in time of switch and sleep and manic ratings before and after switch. Acta Psychiatr. Scand., 58, 267–78.Google Scholar
Soames, M. (1993). Life with my father Winston. Observer, Feb 14th, 49–50.Google Scholar
Storr, A. (1969). Churchill: the man. In: Churchill's Black Dog and Other Phenomena of the Human Mind. London: HarperCollins., pp. 3–51.
Strakowski, S. M., McElroy, S. L., Keck, P. E., et al. (1996). Suicidality among patients with mixed and manic bipolar disorder. Am. J. Psychiatry, 153, 674–6.Google Scholar
Suppes, T., Webb, A., Paul, B., et al. (1999). Clinical outcome in a randomized one-year trial of clozapine versus treatment as usual for patients with treatment resistant illness and a history of mania. Am. J. Psychiatry, 156, 1164–9.Google Scholar
Swann, A. C., Koslow, S. H., Katz, M. M., et al. (1987). Lithium treatment of mania: cerebrospinal fluid and urinary monoamine metabolites and treatment outcome. Arch. Gen. Psychiatry, 44, 345–54.Google Scholar
Swann, A. C., Stokes, P. E., Casper, R., et al. (1992). Hypothalamic–pituitary–adrenocortical function in pure and mixed mania. Acta Psychiatr. Scand., 85, 270–4.Google Scholar
Swann, A. C., Secunda, S. K., Katz, M. M., et al. (1993). Specificity of mixed affective states, clinical comparison of dysphoric mania and agitated depression. J. Affect. Disord., 28, 81–9.Google Scholar
Swann, A. C., Stokes, P. E., Secunda, S. K., et al. (1994). Depressive mania versus agitated depression: biogenic amine and hypothalamic–pituitary–adrenocortical function. Biol. Psychiatry, 35, 803.Google Scholar
Swann, A. C., Bowden, C. L., Morris, D., et al. (1997). Depression during mania: treatment response to lithium or divalproex. Arch. Gen. Psychiatry, 54, 37–42.Google Scholar
Szabadi, E., Gaszner, P. and Bradshaw, C. M. (1981). An investigation of the alpha-adrenoceptor blocking properties of neuroleptics in the human iris in vivo. Br. J. Clin. Pharmacol., 11, 416–17.Google Scholar
Thase, M., Mallinger, A., McKnight, D., and Himmelhoch, J. (1992). Treatment of imipramine-resistant recurrent depression, IV: a double-blind crossover study of tranylcypromine for anergic bipolar depression. Am. J. Psychiatry, 149, 195–8.Google Scholar
Thomas, A. J., O'Brien, J. T., Davis, S., et al. (2002). Ischemic basis for deep white-matter intensities in major depression. Arch. Gen. Psychiatry, 59, 785–92.Google Scholar
Tohen, M., Tsuang, M. T., and Goodwin, D. C. (1992). Prediction of outcome in mania by mood congruent or mood incongruent psychotic features. Am. J. Psychiatry, 149, 1580–4.Google Scholar
Tohen, M., Sanger, T. M., McElroy, S. L., et al. (1999). Olanzapine versus placebo in the treatment of acute mania. Am. J. Psychiatry, 156, 702–9.Google Scholar
Tohen, M., Jacobs, T. G., Grundy, S. L., et al. (2000). Efficacy of olanzapine in acute bipolar mania: a double-blind, placebo-controlled study. Arch. Gen. Psychiatry, 57, 841–9.Google Scholar
Tohen, M., Chengappa, K. N. R., Suppes, T., et al. (2002a). Efficacy of olanzapine in combination with valproate or lithium in the treatment of mania in patients partially non-responsive to valproate or lithium monotherapy. Arch. Gen. Psychiatry, 59, 62–9.Google Scholar
Tohen, M., Baker, R. W., Altshuler, L. L., et al. (2002b). Olanzapine versus divalproex in the treatment of acute mania. Am. J. Psychiatry, 159, 1011–17.Google Scholar
Tohen, M., Goldberg, J. F, Gonzalez-Pinto Arrillaga, A. M., et al. (2003). A 12-week, double-blind comparison of olanzapine vs. haloperidol in the treatment of acute mania. Arch. Gen. Psychiatry, 60, 1218–26.Google Scholar
Wehr, T. A. and Goodwin, F. K. (1987). Can antidepressants cause mania and worsen the course of affective illness?Am. J. Psychiatry, 144, 1403–11.Google Scholar
White, E., Cheung, P., and Silverstone, T. (1993). Depot antipsychotics in bipolar affective disorder. Int. Clin. Psychopharmacol., 8, 119–22.Google Scholar
Winnicott, D. W. (1935). In Through Paediatrics to Psychoanalysis, chapter 9. London: Hogarth Press.
World Health Organization (1993). Tenth Revision of International Classification of Diseases. Geneva: World Health Organization.
Yatham, L. N. (2000). Safety and efficacy of risperidone as combination therapy for the manic phase of bipolar disorder: preliminary findings of randomized, double-blind study (RIS-INT-46). Int. J. Neuropsychopharmacol., 3 (suppl. 1), 142.Google Scholar
Yatham, L. N., Liddle, P. F., Shiah, I.-S., et al. (2002). PET study of [18F]6-fluoro-l-dopa uptake in neuroleptic- and mood-stabiliser-naive first-episode nonpsychotic mania: effects of treatment with divalproex sodium. Am. J. Psychiatry, 159, 768–74.Google Scholar

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