Presentations of depression in bipolar illness

In this paper, a variety of components and treatment characteristics of bipolar depression are addressed. In a large sample of intensively and naturalistically treated outpatients with bipolar illness, daily prospective ratings for 1 year showed that the total time spent depressed exceeded time spent manic by a factor of three, indicating that the depressive phases of bipolar illness in this sample were more problematic and treatment-resistant than the manic phases. Two-thirds of these patients remained substantially impaired by their illness and only one-third had minimal symptoms for the entire year. New data on discontinuation of effective adjunctive antidepressant treatment, in a small subgroup of patients initially responsive for 2 months, suggests that discontinuation may increase the risk of relapse into depression. Different patterns of treatment-resistance to mood stabilizers are discussed, including the possibilities of tolerance development and discontinuation-induced refractoriness. The characteristic phenomenological presentation and neurocognitive deficits of bipolar depression are briefly outlined. The occurrence of an earlier age of onset of depression and bipolar illness are discussed in relation to cohort and anticipation mechanisms and their possible association with the development of treatment-resistance.