Bipolar spectrum disorder masquerading as treatment resistant unipolar depression

We are frequently consulted by patients with treatment resistant depression (TRD).Reference Fogelson and Leuchter¹ Many of these patients have never met criteria for a manic episode so they are not diagnosed with bipolar disorder (BPD). Consequently, they have undergone trials of antidepressants with or without augmentation therapies without success.Reference Perlis, Uher and Ostacher² Antidepressants have caused increased agitation and anxietyReference Perlis, Smoller, Fava, Rosenbaum, Nierenberg and Sachs^3, Reference Perugi, Pacchiarotti and Mainardi⁴ or have been ineffective. We believe that many of these patients would receive effective treatment if they were reconceptualized to be suffering from bipolar spectrum disorder (BPSD) and treated for bipolar depression. The diagnosis of major depressive disorder (MDD) with mixed featuresReference Koukopoulos and Sani^5, Reference Suppes and Ostacher⁶ is not the same as a diagnosis of BPSD and will lead to too few patients reconceptualized as suffering from BPSD. We shall review the history and clinical characteristics of a patient with BPSD, only one of which (see Figure 1, item 8) refers to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM 5) criteria for a mixed state.