uestion: Which type of bipolar depression does the patient have?

• Bipolar I (not rapid cycling)
• Bipolar II (not rapid cycling)
• Bipolar I or II with Rapid Cycling

Help: Use DSM-IV criteria. Some important features are:

Bipolar I: Depressions occur with full mania(s), which last at least a week and have either elevated, euphoric mood plus 3 additional criteria, or irritable mood plus four criteria.

Bipolar II: Depressions alternate with hypomania(s) that last at least 4 days and involve a change in functioning that is observable by others but does not result in marked impairment or hospitalization.

Rapid Cycling: At least four episodes (either mania or depression) per year. A switch directly from, for example, mania to depression without an euthymic interval would count as two episodes.

An algorithm is not provided for Bipolar I disorder, Mixed episodes. Such patients meet full DSM-IV criteria for mania, as well as major depression, and are conceptualized as having a subtype of mania. They are covered in algorithms for the treatment of mania. Most experts consider monotherapy with divalproex sodium the first-line pharmacotherapy, with secondary evidence for carbamazepine. Lithium appears to be much less effective.¹

If you are unsure about the diagnosis, follow the algorithm answering the questions appropriately for each possible diagnosis. You will receive recommendations for treatment. Compare the recommendations for each diagnostic possibility. There may be a treatment option that covers both diagnoses. This might be the treatment of choice that "covers" the diagnostic ambiguity.

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¹Bowden CL, Brugger AM, Swann AC, et al. Efficacy of divalproex vs lithium, placebo in the treatment of mania. JAMA. 1994;271:918-924.