The nature and treatment of depression in bipolar disorder: A review and implications for future psychological investigation

doi:10.1016/j.cpr.2005.06.007

Clinical Psychology Review

Volume 25, Issue 8, December 2005, Pages 1076-1100

https://doi.org/10.1016/j.cpr.2005.06.007 Get rights and content

Abstract

Bipolar depression is poorly understood and researched, yet it is has a huge impact on functioning in bipolar disorder. This review explores the current status of research regarding the phenomenology, natural history, neuropsychology, psychosocial predictors and cognitive style of bipolar depression. The current status of pharmacotherapy and psychological treatment of bipolar depression is also described. In particular, the manner in which cognitive behaviour therapy for bipolar depression has been adapted from CBT for unipolar depression is critically evaluated. It is concluded that there appears to be a considerable overlap between the features of unipolar and bipolar depression, yet there is also emerging evidence for specific elements. The ability of current psychological theories of bipolar disorder to account for the findings are compared, and as a consequence, a new preliminary integrative model is proposed to direct future hypothesis-led research, which will need to incorporate more suitable populations and utilise more objective methods of assessment.

Section snippets

Clinical description and symptoms

Around 90% of patients who experience mania will also experience depression (Goodwin & Jamison, 1990). Indeed several investigators have suggested that the minority of patients who appear to report unipolar mania tend to reveal untreated depressive episodes after a careful history is taken (Pfohl, Vasquez, & Nasrallah, 1982). The majority of bipolar I patients will have reoccurrences of both mania and depression (Roy-Byrne et al., 1985). Within the population of individuals with bipolar II

Summary of findings and implications for theory and research

As emphasised throughout, much of the evidence for differences between unipolar and bipolar depression across each of the domains described above is either inconsistent, provided by only one or two studies, or does not involve adequate controls. Factors such as early onset, mood lability and a family history of bipolar disorder provide some potential diagnostic information but they do not help us understand the psychological mechanisms involved. We reviewed emerging evidence that symptoms of

A provisional integrative account of bipolar depression

It is clear that the three sets of theoretical accounts are broadly consistent with the findings, but none is directly supported or contradicted by them. In each case, we have identified key hypothesis-driven studies that would have the capacity to do so. Future developments in psychological theory may need to take account of the close overlap between existing psychological accounts. In a provisional formulation, we propose that bipolar depression is maintained by the co-occurrence of a

Pharmacological treatment of depression

Since the middle of the last century, pharmacological treatments have largely dominated the treatment of bipolar disorder. Here we provide an overview of the current pharmacological treatment approach to bipolar depression (for more comprehensive reviews, see Altshuler et al., 2003, Gijsman et al., 2004, Keck et al., 2003).

Yatham, Calabrese, and Kusumakar (2003) have suggested that an acceptable first-line pharmacotherapy for bipolar depression should:

•
Be an effective treatment for acute

Summary and conclusions

We have provided an overview of symptom profiles, neuropsychological factors, psychosocial predictors, cognitive styles and treatment protocols associated with bipolar depression. Evidence from each of these domains is consistent in highlighting an overlap between unipolar and bipolar depression, yet there are also potential differences that need to be investigated in a well-controlled, hypothesis-led fashion. Depression, whether unipolar or bipolar, is likely to be preceded by negative

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Comorbid anxiety is common in bipolar spectrum disorders [BPSD], and is associated with poor outcomes. Its clinical relevance is highlighted by the “anxious distress specifier” in the revised criteria for Bipolar Disorders in the Diagnostic and Statistical Manual 5th Edition [DSM-5]. This article reviews evidence for the effectiveness of psychological therapy for anxiety in adults with BPSD (bipolar I, II, not otherwise specified, cyclothymia, and rapid cycling disorders). A systematic search yielded 22 treatment studies that included an anxiety-related outcome measure. Cognitive behavioural therapy [CBT] for BPSD incorporating an anxiety component reduces anxiety symptoms in cyclothymia, “refractory” and rapid cycling BPSD, whereas standard bipolar treatments have only a modest effect on anxiety. Preliminary evidence is promising for CBT for post-traumatic stress disorder and generalised anxiety disorder in BPSD. Psychoeducation alone does not appear to reduce anxiety, and data for mindfulness-based cognitive therapy [MBCT] appear equivocal. CBT during euthymic phases has the greatest weight of evidence. Where reported, psychological therapy appears acceptable and safe, but more systematic collection and reporting of safety and acceptability information is needed. Development of psychological models and treatment protocols for anxiety in BPSD may help improve outcomes.
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Cognitive dysfunction is of clinical significance and exerts longstanding implication on patients׳ function. Pharmacological and non-pharmacological treatments of cognitive dysfunction are emerging. This review evaluates pharmacological and non-pharmacological treatments of cognitive impairment primarily in the domains of memory, attention, processing speed and executive function in clinical depression. A total of 35 studies were retrieved from Pubmed, PsycInfo and Scopus after applying inclusion and exclusion criteria. Results show that various classes of antidepressants exert improving effects on cognitive function across several cognitive domains. Specifically, studies suggest that SSRIs, the SSRE tianeptine, the SNRI duloxetine, vortioxetine and other antidepressants such as bupropion and moclobemide may exert certain improving effects on cognitive function in depression, such as in learning and memory and executive function. Class-specific cognitive domains or specific dose–response relationships were not identified yet. The few non-pharmacological studies conducted employing cognitive orientated treatments and cognitive remediation therapy show promising results for the improvement of cognitive impairment in depression. However, several methodological constraints of studies limit generalizability of the results and caution the interpretation. Future direction should consider the development of a neuropsychological consensus cognitive battery to support the discovery, clinical assessment, comparison of studies and registration of new agents in clinical depression.
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Unipolar and bipolar depressions are frequently associated with dysfunction across a range of neurocognitive domains, including attention, executive functions, as well as learning and memory (Marvel and Paradisø, 2004; Haldane and Frangou, 2006). Patterns of cognitive impairments are similar in unipolar and bipolar depression (Quraishi and Frangou, 2002; Marvel and Paradisø, 2004) but deficits are more severe in BD (Murphy and Sahakian, 2001; Mansell et al., 2005). A number of studies have demonstrated cognitive deficits in attention with regard to alertness (McIntosh et al., 2005; Pardo et al., 2006), information processing speed (Tsourtos et al., 2002; Burdick et al., 2009), vigilance and sustained attention (Porter et al., 2003; Depp et al., 2007), as well as selective (Politis et al., 2004; Burdick et al., 2009) and divided (Lemelin and Baruch, 1998) attention.
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The nature and treatment of depression in bipolar disorder: A review and implications for future psychological investigation

Abstract

Section snippets

Clinical description and symptoms

Summary of findings and implications for theory and research

A provisional integrative account of bipolar depression

Pharmacological treatment of depression

Summary and conclusions

Journal of Affective Disorders

Biological Psychiatry

Journal of Affective Disorders

Journal of Affective Disorders

Clinical Psychology Review

Journal of Psychiatric Research

Journal of Affective Disorders

Journal of Affective Disorders

Journal of Affective Disorders

Psychiatric Clinics of North America

Journal of Affective Disorders

Clinical Psychology Review

Biological Psychiatry

Journal of the American Academy of Child and Adolescent Psychiatry

Journal of Affective Disorders

Biological Psychiatry

Personality and Individual Differences

Notes on the psycho-analytical investigation and treatment of manic-depressive insanity and allied conditions

Switching from “unipolar” to bipolar II: An 11-year prospective study of clinical and temperamental predictors in 559 patients

Archives of General Psychiatry

Subsyndromal depression is associated with functional impairment in patients with bipolar disorder

Journal of Clinical Psychiatry

Practice guideline for the treatment of patients with bipolar disorder (revision)

American Journal of Psychiatry

Course of a clinical cohort of unipolar, bipolar and schizoaffective patients. Results of a prospective study from 1959 to 1985

Archiv fur Neurologie und Psychiatrie

Periodicity of depressive psychoses

Cognitive-behavioral therapy for bipolar disorder

Reduction of prefrontal cortex glucose metabolism common to three types of depression

Archives of General Psychiatry

The neuropsychology and neuroanatomy of bipolar affective disorder: A critical review

Bipolar Disorders

Unipolar and bipolar affective illness: Differences in clinical characteristics accompanying depression

Archives of General Psychiatry

The Montgomery Asberg Depression Rating Scale in bipolar II and unipolar outpatients: 405 patient case study

Psychiatry and Clinical Neurosciences

Madness explained: Psychosis and human nature

Depression, demoralization and control over psychotic illness: A comparison of depressed and non-depressed patients with a chronic psychosis

Psychological Medicine

Neuropsychological frontal lobe tests indicate that bipolar depressed patients are more impaired than unipolar

Bipolar Disorders

Pharmacotherapy for bipolar depression: An economic assessment

Expert Opinion on Pharmacotherapy

Learning and memory in bipolar and unipolar major depression: Effects of aging

Neuropsychiatry, Neuropsychology, and Behavioral Neurology

A factor analysis of the signs and symptoms of mania

Archives of General Psychiatry

Preventing medication non-compliance in the outpatient treatment of bipolar affective disorders

Journal of Consulting and Clinical Psychology

A randomised trial on the efficacy of group psychoeducation in the prophylaxis of recurrences in bipolar patients whose disease is in remission

Archives of General Psychiatry

Psychological treatments of bipolar depression

Long-term stability of polarity distinctions in the affective disorders

American Journal of Psychiatry

A theoretical reappraisal of mixed states: Dysphoria as a third dimension

Bipolar Disorders

A two-dimensional threshold model of seasonal bipolar affective disorder

Does maintenance lithium therapy prevent recurrences of mania under ordinary clinical conditions?

Psychological Medicine

Suicidality in patients with pure and depressive mania

American Journal of Psychiatry

Depressive mania associated with nonresponse to antimanic agents

American Journal of Psychiatry

Perception and cognition in patients with bipolar and unipolar depressive disorders: A study in Rorschach responding

Archives of General Psychiatry

Depression in inpatients: Bipolar vs unipolar

Psychological Reports

A review of the diagnostic status of “Bipolar II” for the DSM-IV work group on mood disorders

Depression

Life events and the course of bipolar disorder

American Journal of Psychiatry

The expert consensus guidelines for treating depression in bipolar disorder