BIPOLARITY: BEYOND CLASSIC MANIA 0193-953X/99 $8.00 + .

OO

THE ROLE OF BIPOLARITY IN

DEPRESSION IN THE FAMILY
PRACTICE SETTING
J. Sloan Manning, MD, Radwan F. Haykal, MD,
and Hagop S. Akiskal, MD

Family practice training in psychiatry relies heavily on nonphysician

behavioral disciplines, such as clinical psychology and social work. As
a result, there is less emphasis on sophisticated psychopharmacologic
interventions for patients with mood disorders. Education about mood
disorders is often simplistic-if not archaic-with endogenous depressions
requiring somatic interventions and reactive depressions relegated to
talk therapies. Furthermore, the subtler forms of depression, such as
dysthymias, are often unnoticed or misinterpreted as character flaws-
weak people unwilling to deal effectively with stress-and thus beyond
pharmacotherapy. These stereotypes are relics from psychiatric teaching
during the 1960s and 1970s. Psychiatry has since been revolutionized,
but the new thinking has not permeated primary care medicine. Psychi-
atric training of physicians in the primary health sector is highly variable
and usually ignored when compared to the prevalence and associated
costs of such illness in generalist settings.35Obstetrician-gynecologists,
who exclusively see the most vulnerable portion of the population at
risk for mood disorders, receive no required psychiatric training at all.
All such factors limit a primary care physician’s ability to recognize and
treat mood disorders.31,37-39
Issues in provider education are further complicated by the fact

From the Departments of Family Medicine (JSM, RFH) and Psychiatry (RFH), University
of Tennessee; Charter Lakeside Behavioral Health System (RFH), Memphis, Tennessee;
and Department of Psychiatry and International Mood Center, University of California
at San Diego (HSA), La Jolla, California

THE PSYCHIATRIC CLINICS OF NORTH AMERICA

-
VOLUME 22 NUMBER 3 SEPTEMBER 1999 689
690 MANNINGetal

that comparatively few depressed patients respond fully to treatment.

Although up to 60% to 70% of depressions improve with antidepres-
sants, in practice, substantially fewer patients have robust, sustained
relief from depressive symptoms with any single medication.'l Many
experience suboptimal improvement or show no response. Others have
short-lived, erratic, or exaggerated antidepressant responses. Paradoxi-
cally, antidepressants worsen depression in some patients-at times dra-
matically with agitation and increased suicidality. The media has publi-
cized such adverse outcomes in fluoxetine based on a biased clinical
sample41; agitated depressive mixed states have been described in a
substantial minority of soft bipolar depressives inappropriately treated
with aggressive antidepressant monotherapy preceding the selective se-
rotonin reuptake inhibitor era.5That some depressed patients apparently
given adequate doses of antidepressants get worse rather than better
raises concerns about the efficacy and safety of treatment and may make
primary care interventions even less likely.
A review of the psychiatric literature suggests that a significant
part of the treatment quandary may be the result of unrecognized or
underestimated soft (nonmanic) bipolarity.' Erratic antidepressant re-
sponses and confusing clinical pictures described are all common in
such patients', 5,44 and validated in the authors' work in the family
practice setting.25-28 The early diagnosis of bipolar illness may lead to
more precise treatments, fewer complications from inappropriate antide-
pressant monotherapy, and improved patient outcomes.
This article briefly presents the cross-sectional and longitudinal litera-
ture on mood disorders in primary care, then focuses on common clinical
presentations of bipolar illness in that setting. It describes hypomania as a
state-as well as temperamental features of soft bipolarity-and discusses
the implications of failing to diagnose bipolar illness properly in this
setting, culminating in a clinical approach that addresses common pit-
falls in patient assessment.

DEPRESSION IN PRIMARY CARE

Investigations of the types of depressive illness present in primary

care settings have been largely cross-sectional, with screened waiting
room patients subsequently evaluated by structured inter vie^.'^-'^, 20, 23,
30* 46 These interviews are insensitive to hyp~mania.'~ Not surprisingly,
bipolar illness was rarely identified. Only one investigation of this type
(using the Structured Clinical Interview for the Diagnostic and Statistical
Manual of Mental Disorders, third edition, revised [DSM-III-RI9)found
bipolarity in 10% of its sample.I6The validity of the diagnostic interview
is not the only problem inherent in the identification of bipolarity in
these studies. Cross-sectional evaluations by the nonclinicians that typi-
cally perform such interviews are unlikely to categorize these patients
correctly. Family history, longitudinal observation, and clinician experi-
ence are required to make the most meaningful diagnosis. Long-term
 THE ROLE OF BIPOLARITY IN DEPRESSION IN THE FAMILY PRACTICE SETTING 691

evaluation by psychiatrists who have access to all possible sources of

information is the gold standard for psychiatric diagnosis.40When these
principles were applied to the question of depressive and anxious sub-
types in a private primary care settinglz7a picture different from that
painted by the epidemiology-based literature emerged (Table 1):Bipolar
illness constituted one third of the affectively ill patients in this longitu-
dinal clinical investigation. Although the figures are preliminary, they
are buttressed by data from research in the authors' family practice
mood clinic (Table 2) and are well in line with the emerging world
literature on soft bipolar illness."

PHENOMENOLOGY OF HYPOMANIA

Hypomanic episodes can be difficult to detect in clinical practice.

One reason is that hypomanias typically last only 1 to 3 days.45The
DSM-IV'O criterion of a 4-day duration substantially reduces diagnostic
sensitivity. Hypomanic patients experience an expansive, elated mood
and are often socially and occupationally quite productive. There is
therefore a tendency to view hypomania as normal. This tendency hides

Table 1. PRIMARY DIAGNOSES FOR DEPRESSED AND ANXIOUS PATIENTS

(N = 108)
No. Gender % Total
Diagnosis Patients Female/Male Patients
DNOS with History of MDD 26 24.1
Bipolar spectrum* 28 25.9
Bipolar I 3 2.8
Bipolar I1 20 18.5
Bipolar IIIt 4 3.7
Cyclothymic disordert 1 0.9
Dysthymic disorder$ 17 15.7
MDD 15 13.8
Panic disorder 9 8.3
Obsessive-compulsive disorder 3 2.8
Generalized anxiety disorder without 3 2.8
history of MDD or DNOS
DNOS without history of MDD 2 1.9
Posttraumatic stress disorder 1 0.9
Active chemical dependence 3 0.9
Adjustment disorder with depressed 1 0.9
mood

*The figure of 25.9% is derived by considering the total sample, which includes non-mood disorder
diagnoses. If the denominator is limited to mood disorders, the rate of bipolar spectrum conditions
rises to 31%.
tMajor depression in the absence of documented hypomanic episodes but with hyperthymic
temperament, bipolar family history, or both.
SIn the absence of major depression.
DNOS = Depression not otherwise specified; MDD = major depressive disorder.
Summarizedfrom Manning et aLz7
692 MANNINGetal

Table 2. PRIMARY DSM-IV DIAGNOSES IN A FAMILY PRACTICE MOOD DISORDER

CLINIC ( N = 187)
Diagnoses N YO
Primary mood/anxiety diagnoses
Bipolar disorders (I, 11, NOS) 73 39
Major depressive disorder 45 24
Depression NOS 13 7
Dysthymic disorder* 9 5
Obsessive-compulsive disorder* 8 4
Generalized anxiety disorder* 7 4
Panic disorder* 5 3
Posttraumatic stress disorder* 2 1
Total mood/anxiety diagnoses 162 87
Other primary diagnoses
Substance abuse 5 3
Seizure disorder 4 2
Intermittent explosive disorder 2 1
Paranoid schizophrenia 2 1
Hypothyroidism 2 1
Mixed syndrome headache 2 1
Microcytic anemia 1 0.5
Fatigue 1 0.5
Parent-child concerns 1 0.5
Marital problems 1 0.5
Adjustment disorder 1 0.5
Organic mood disorder 1 0.5
Back pain 1 0.5
Grief reaction 1 0.5
Total other primary diagnoses 25 13

*Without evidence for independent major depressive syndrome.

EM-IV = Diagnostic and Statistical Manual @Mental Disorder, 4th edition.
Summarized from Manning et a1.l2

crucial diagnostic data because patients do not feel the need to report
wellness to their physicians. Conversely, physicians are unlikely to probe
for this information, resulting in the loss of a crucial diagnostic marker.
In addition, clinicians often rely on clinical snapshots for the bulk of
their diagnostic impressions, failing to plot the longitudinal course of
the patient’s symptoms to look for evidence of hypomania or other
bipolar features. They may not scrutinize the course of somatic therapy
for patterns of response typical in those with unfavorable outcomes with
antidepressant monotherapy for bipolar illness (i.e., switching, lability,
cycling). Unstable romantic, occupational, and geographic histories may
prompt clinicians to overemphasize Axis I1 maladaptive character faults
at the expense of treatable Axis I illness. Although the psychiatric litera-
ture is now documenting a high prevalence of bipolarity; most primary
care physicians have not been exposed to this literature. They simply do
not know that such a spectrum exists. Figure 1 provides a graphic
illustration of the key elements of the hypomanic syndrome. Table 3
contains a list of suggested questions for uncovering hypomania.
That the diagnostic process of identifying bipolar I1 disorder may
 Hypomanic Episode
1. Increased mentavphysical activity

2. Decreased need for sleep

3. Talkativeness

4. Qpically elated, occ. dysphoric

5. Tendency for impairment of social judgement Euthymic Mood

6. Without adequate cause
Hypersomnic, Retarded Depression
I
7. Labile

8. Recurrent

1-3 Days Typical

Figure 1. Hypomanic episode and euthmic mood. Elated mood may become mixed with depressive symptoms as the episode progresses.
Hypersomnic, retarded depressions often proceed and follow hypomanic expansions of mood. The baseline from which hypomanic episodes arise
is typically one of chronic mixed anxious depressions. The shift from lethargy and depressed mood into productivity and elation is welcomed and
perceived as normal. OCC = occasionally.
694 MANNING et a1

Table 3. DETECTING HYPOMANIA

Characteristics of Hypomania"
No adequate cause or grossly disproportionate to the situation
Labile-often with sudden onset and offset-switching to normal or down period
Can be dysphoric in drivenness, although mood is typically elated
Not psychotic-yet tends to impair judgment in personal life
Often preceded or followed by retarded depression
A recurrent condition
If the typical features are present, 48 hours' duration is sufficient to make diagnosis
Suggested Probes for Uncovering Hypomaniat
Do you have days of energy or ideas that come and go abruptly?
On those days of energy, are you productive? Positive about the future? Convinced of
your self-worth, talents, and abilities? Talkative? Distinctly more social? Irritable? Feel
unconquerable?
On those days of energy, do your thoughts feel as if they are racing?
At night during this period of energy, do you continue to be active, needing less sleep?
Get new ideas or make all kinds of plans for the future?
How many consecutive days does this period of increased energy and change in mood
last?
Do others notice the change in your mood or energy level?
During these up periods, do you do things that you later regret? Make plans you find
impossible to follow through? Take on tasks that you later lose interest in or find you
are without the energy or desire to complete?
Are you particularly more depressed or lethargic immediately before or immediately
after the cessation of these periods of energy? Does it feel like you crush? Do you need
excessive sleep?

*Modified from Akiskal and M a l l ~ a . ~

tBased on Manning et a1.26

benefit from a consideration of long-term temperamental traits is exem-

plified in a prospective investigation within the National Institute of
Mental Health (NIMH) Collaborative Study of Depression.6 It revealed
that four temperamental factors are predictive of switching from a uni-
polar to a bipolar (usually bipolar 11) diagnosis. Mood lability, energy-
activity, daydreaming, and social anxiety were the most sensitive for
predictive bipolar I1 outcome and thus appear preferable to the cross-
sectionally identified hypomanic episodes emphasized in DSM-IV. Of
the four factors, the most specific were the first two, mood lability and
energetic-activity, which prior work had delineated as cyclothymic and
hyperthymic temperaments.2, (Table 4 outlines these temperaments as
refined by more recent re~earch.~) The NIMH study also explains why
prebipolar or switching depressive patients may be misdiagnosed as
borderline personality disorder: The four factors, when examined from
the perspective of Axis 11, often display an unstable admixture of cluster
B (erratic) and cluster C (anxious) personality traits. Increasingly, a new
generation of psychiatrists is cognizant of the fact that the interpersonal
operations characteristic of clusters C and B constructs might reflect a
treatable underlying mood disorder, and Axis I1 diagnosis should be
suspended until rigorous treatment is instituted for the mood disorder.
 THE ROLE OF BIPOLARITY IN DEPRESSION IN THE FAMILY PRACTICE SETTING 695

Table 4. CRITERIA FOR AFFECTIVE TEMPERAMENTS MOST RELEVANT TO SOFT

BIPOLARITY

Hyperthymic Temperament
Overinvolved and meddlesome
Overconfident, self-assured, boastful, or grandiose
Overtalkative and jocular
Cheerful, overoptimistic, or exuberant
Warm, people-seeking, and extroverted
High energy level; full of improvident activities
Unhibited, stimulus seeking, or sexually driven
Cyclothymic Temperament
Intermittent short cycles with infrequent euthymia
Decreased verbal output alternating with talkativeness
Lethargy alternating with eutonia
Pessimism and brooding alternating with optimism and care-free attitudes
Frequent shift in work, study, interest, or future plans
Unexplained tearfulness alternating with excessive punning and jocularity
Shaky self-esteem alternating between lack of self-confidence and naive or grandiose
overconfidence
Periods of mental confusion and apathy, alternating with periods of sharpened and
creative thinking
Uninhibited people-seeking (hypersexuality may result) alternating with introverted self-
absorption

Based on Akiskal and Mallya5 and Akiskal et al.?

The foregoing considerations explain why bipolar illness is underdi-

agnosed in a family practice setting more often than in modern clinical
psychiatry. Certain common patient presentations typify the existing
obstacles and are illustrated by a case series from the authors’ primary
care ambulatory setting.

CASE EXAMPLES

Case No. 1. Hypomania Exacerbated by Antidepressant

Treatment in a Clinically Depressed Patient With
Cyclothymic Temperament
Cindy was a 26-year-old white woman who presented with hypersomnia
and hyperphagia. During the morning, her anergia, inertia, and cognitive slow-
ing bordered on stupor. A neurologic workup performed with the suspicion of
a midline brain tumor had been completely negative. Cindy had experienced
many such episodes, beginning at menarche. She was on no medication at the
time of her initial presentation. The current episode had lasted for 6 weeks
ostensibly triggered by the breakup of a romance.
Cindy’s romances were stormy affairs. She was often verbally and physi-
cally aggressive. Cindy had abused stimulant diet pills and alcohol in the past
but had not used these in at least a year. She was hospitalized at age 21 after a
696 MANNINGetal

similar romantic entanglement. At that time, she was treated with adequate
doses of nortriptyline, which had proven ineffective. She had been diagnosed as
having borderline personality disorder. Severe agitation, an overdose of over-
the-counter sleeping pills, and one episode of self-mutilation marked previous
depressions. Cindy’s mother described her behavior as unpredictable. Cindy’s
father was an alcoholic, as were multiple members of his side of the family.
Cindy’s mother suffered from chronic anxiety with panic attacks.
Fluoxetine (newly available at that time) was prescribed at 20 mg/d. She
was encouraged to continue individual psychotherapy. At her 2-week follow-up
visit, Cindy arrived in great spirits-smiling, laughing, and exclaiming, ”I’m
singing again!” She related waking up in a completely different frame of mind
after 8 days of fluoxetine treatment. Her mood was exalted. She was sleeping
only 3 to 4 hours a night, waking with racing thoughts. A conversation with her
mother confirmed the sudden change in mood and the presence of talkativeness
and plans for attending college. On specific questioning, she revealed similar
episodes of exalted mood, although none in recent memory were as intense or
long-lasting. Accordingly, lithium 600 mg/d (0.5 mEq/L) was added to the
fluoxetine. Cindy’s mood stabilized at a euthymic level on the combined regi-
men. Subsequently, she found employment at a local grocery store, rising to a
management position over the next 2 years. She has sustained this response
through 5 years of follow-up.

Treatment-emergent hypomania typically occurs within the first 2

weeks of antidepressant therapy. Cindy’s hypomania was not de novo
but a reemergence of hypomania she had experienced in the past. She
was surprised that a different meaning was assigned to this rapid and
seemingly satisfying response to treatment. Without the introduction of
a mood stabilizer, her hypomania either would have placed her at risk
for lapses of judgment or would have led to chronicity of the depression
(just as it had happened in the past). Temperamental factors also ap-
peared relevant to her hypomanic response to fluoxetine: Cindy clearly
manifested features of the cyclothymic temperament, a putative risk
factor for erratic antidepressant response^.^

Case No. 2. Bipolar Illness Presenting as Panic Disorder

Janice presented as a referral from a local cardiologist.A 33-year-old smoker,
she had recently undergone a cardiac catheterization prompted by an emergency
department evaluation for chest pain and shortness of breath. That visit was one
of many for Janice. Her cardiologist was concerned that her obviously anxious
moods not prevent the proper diagnosis of underlying coronary artery disease.
A cardiac catheterization was negative, and she was prescribed alprazolam, a
medication with which she was familiar from previous emergency department
visits.
Janice had been treated unsuccessfully with antidepressants for panic disor-
der several times. Imipramine caused drowsiness and constipation. Nortriptyline
and three selective serotonin reuptake inhibitors brought about severe increases
in anxiety and restlessness at small doses. Her use of alprazolam (1 mg three
times a day) had became a treatment of last resort for her panic attacks.
An evaluation of her temperament revealed lifelong mood lability with
periods of exuberance alternating with times of social withdrawal. Brief, but
 THE ROLE OF BIPOLARITY IN DEPRESSION IN THE FAMILY PRACTICE SETTING 697

intense depressive episodes occurred six to seven times a year, often, although
not always, when she was premenstrual. The emergence of the panic attacks
had led to severe dysfunction, however. She was a homemaker with two children
by a second marriage. The family history was positive for alcoholism in a
maternal aunt. She described her mother as superwoman-a real estate agent
with boundless energy and unconquerable enthusiasm, a pillar of the community.
Her mother’s father had been hospitalized for a mental disorder as a young
man: He was known to be excitable most of his life, and he died in prison after
a murder conviction for a passionate crime involving alcohol and jealousy about
a lover.
Janice’s clinical picture suggested cyclothymic lability and a hyperthymic
temperament in the mother, with a family history pointing toward bipolar
disorder. She was prescribed valproate with a final dose of 750 mg/d (50-60
ng/dL). She experienced a remarkable calming of her mood and anxiety over 2
months. Her panic attacks completely ceased. She eventually was weaned off
alprazolam except for rare doses taken as needed for insomnia. She did well
over a follow-up of 18 months.

Anxiety disorders often coexist with bipolar illness. Panic attacks

usually prompt physician visits; hypomania rarely does. Consequently,
antidepressants may be used as monotherapy in patients with panic
attacks and unrecognized bipolar illness. When antidepressants are
poorly tolerated, benzodiazepines may become treatments by default.
Estimates of the comorbidity of panic disorder and bipolar disorder
range from 25% to 33%.33,36One third of the bipolar patients in the
authors’ longitudinal study experienced panic attacks.27It makes sense
to consider bipolar illness in every patient experiencing panic attacks,
particularly those with intense moody temperaments, suggestive family
histories, recurrent depressions, and atypical or reverse neurovegetative
signs.32Finally, there is preliminary evidence that bipolar I1 disorder with
panic attacks might constitute an important familial-genetic

Case No. 3. Bipolarity Presenting as Refractory Depression

With Atypical Features
Ruth, a 53-year-old woman, presented to the authors’ mood disorder clinic.
Although in the past she had been considered as suffering from chronic fatigue
syndrome, her main complaint to the center-”I’ve been moody all my
life’’-was inconsistent with the presentation of chronic fatigue syndrome pa-
tients, who typically vigorously deny depression. Nonetheless, she had been
treated on a number of occasions for fatigue states. Adequate doses of doxepin-
for insomnia at night-alone and in combination with dextroamphetamine-
ostensibly for daytime fatigue-had been totally ineffective. A definite history
of depressions with hyperphagia and hypersomnia as well as complaints of
leaden paralysis was obtained. The one psychiatrist she had consulted in the
past had diagnosed her as atypical depressive, but because of her occasional
indulgence in diet pills, she had not been treated with a monoamine oxidase
inhibitor. She was an interior designer who had won an award for her work but
was unable to attend the award ceremony because of her social anxiety. Her
depressions worsened during the winter. She knew little about her family history
698 MANNING et a1

except for describing her mother as on the nervous side without any known
treatment for a mood disorder.
At initial evaluation, Ruth had been on therapeutic doses of venlafaxine for
several months. She described her mood as a little better overall but added
nonchalantly, "I still have my ups and downs." She described her ups as days
of energy, productivity, light-heartedness, and increased sexual desire. These
periods began and ended abruptly once or twice a month, typically lasting 2 to
3 days but rarely as long as 3 weeks. They included racing thoughts and a
markedly diminished need for sleep but were free of social or occupational
impairment. Much of her work was done during these periods of expansive
mood, and she waited expectantly for their reappearance. These periods of
energy and elation were reliably followed by anergic depressions. Ruth's bipolar
I1 illness responded nicely to lithium augmentation (750 mg/d, 0.7 mEq/L) of
the venlafaxine. She has maintained this response for 1 year and has been
successful at work, gaining acclaim from builders and architects.

The association of atypical depression with bipolar illness is contro-

versial, but an investigati~n~~ found that 72% of atypical major de-
pressives met the criteria for bipolar 11, and 60% had cyclothymic tem-
perament. Clinical prudence dictates that those with atypical depressions
be subjected to close scrutiny. Bipolar depressions often worsen in win-
ter. As in the other two cases, a careful examination of symptoms, family
history, longitudinal course, and treatment response led to the correct
diagnosis-necessary for considering the lithium augmentation that led
to her recovery.

USING THE CLINICAL PROCESS AS A PATHWAY TO

IMPROVEMENT

Mind-body dualism still influences the thinking of physicians. Many

generalists assume that the treatment of mental illness is fundamentally
different from that of general medical conditions. Experience in the
education of family practice residentsz8suggests that the use of a stan-
dard clinical approach applied or made pertinent to psychiatry is a
helpful way to debunk unscientific paradigms and emphasize the proper
consideration of biologic and psychosocial factors. Careful attention to
this approach may improve diagnostic accuracy. A summary of these
basic clinical steps follows.

Screening for Impairment and Dysfunction

For the most part, depressed primary care patients do not complain
of depressed mood or anhedonia at their initial presentation. Alexitkyrniu
is common. Questions intended to uncover mood disorders should begin
with those of high sensitivity (sleep disturbance, anergia, irritability)
and proceed to those with high specificity (depressed mood, lack of
interest). The specialty-specific pseudonyms and medical comorbidities
 THE ROLE O F BIPOLARITY IN DEPRESSION IN THE FAh4ILY PRACTICE SE7TING 699

that accompany depression (e.g., irritable bowel syndrome, mixed ten-

sion-migraine headache, premenstrual syndromes) may identify persons
at risk.34Mood disorders cause pervasive impairments or may be trig-
gered by stressors. Questions about psychosocial context may help target
further inquiries.

Search for Comorbidity

Both medical and psychiatric comorbidities are important to con-

sider. Mood aberrations may influence a general medical condition or
may be triggered by its treatment.l8S29, 42 Further, psychiatric comorbidity
with mood disorders is the rule, not the exception.22Anxiety disorders
of all types, eating disorders, and substance abuse often coexist with
mood disorders. These often point toward soft bipolarity.

Diagnostic Formulation

Clinical diagnoses are validated by considering phenomenology,

pedigree, longitudinal course, treatment response, and biologic marker^.^
With the exception of biologic markers (not yet specific enough), each
of these areas contains clinically useful information in the identification
of bipolar illness. Hypomania and temperamental considerations have
been discussed. The family pedigrees of bipolar patients are often loaded
with first-degree relatives with mood disorders or related conditions.8
Bipolar illness has an earlier onset and higher frequency of episodes
than unipolar illness.

Therapeutic Alliance

A crucial factor in the success of the treatment of mood disorders is

the shared decision making and risk taking in a therapeutic alliance.
Agreement between clinician and patient on the rationale of therapy
and an understanding of the risks, benefits, and potential side effects of
treatment are essential. The patient should be allowed to make reason-
able choices within the context of the clinical situation.

Formulation of Treatment Plan

Any treatment plan must address the elements of biologic underpin-

ning, psychosocial context, and therapeutic milieu. Mood stabilizers are
preferred as the primary medications for bipolar spectrum disorders.
Many patients, however, require combinations of antidepressants and
mood stabilizers for acute and maintenance therapy. Psychosocial ele-
ments should not be minimized inasmuch as stressors often influence the
700 MANNINGetal

timing of morbid episodes, access to care, and social support essential to

treatment adherence. Patients who present as diagnostic dilemmas, pre-
sent with refractoriness to treatment, or are in need of hospitalization
for protection from dangerous impulsivity should be considered for
consultation or referral.

Management

Robust, sustained response is the goal of all treatment. This goal

includes symptomatic improvement and the acquisition or restoration of
normal interpersonal and occupational functioning. The chronic relaps-
ing nature of mood disorders requires the clinician and patient to moni-
tor or anticipate necessary adjustments in the treatment plan. Hypoma-
nia is often difficult to detect but must be anticipated. General medical
conditions may mandate changes in treatment strategy, or treatments for
such conditions may affect a comorbid mood disorder by worsening
depression or destabilizing mood. Substance abuse is often occult and
may require detoxification on its own right. Nonetheless, alcohol and
substance use disorders are, more commonly than believed, complica-
tions of undiagnosed soft bipolar disorders. Anticonvulsant mood stabi-
lization often, although not always, leads to remission from substance
use (see the article by Sonne and Brady in this issue).

CONCLUSIONS

Training of primary care physicians in the diagnosis and treatment

of mood disorders continues to be problematic. There does not seem to
be a standard requirement in different centers, and physicians receive
variable levels of training. Although it is widely acknowledged that
depression is a common and treatable disorder within the purview of
the primary care physician, there has been little attempt to provide
sufficient training in the broad range of mood disorders. As in the
case of developments in clinical psychiatry, experience indicates that
bipolarity-specially bipolar I1 disorder-occurs in one of three patients
in a family practice setting. This is an extremely important consideration
because these are the patients who, after an apparent transient response,
continue to have various patterns of intermittent depressive chronicity,
agitated and excited behavior, and even frequent cycling. The recogni-
tion of this phenomenon is important for public health, and a broad
diagnostic approach that focuses on family history for bipolar disorders,
longitudinal course, temperamental factors, and psychopharmacologic
sophistication with the use of mood stabilizers is necessary. To compli-
cate matters, panic attacks may also occur in the context of these cryptic
bipolar patients, creating diagnostic uncertainties; these patients are
particularly oversensitive to antidepressants and often develop para-
 THE ROLE OF BIPOLARITY IN DEPRESSION IN THE FAMILY PRACTICE SETTING 701

doxic excitement. Again, anticonvulsant mood stabilizers may prove

beneficial for many of these patients. In brief, although general prac-
titioners are not expected to acquire in-depth psychiatric training, they
need more skills than the identification and treatment of the affective
disorders beyond unipolarity.

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