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80 Journal of The Association of Physicians of India ■ Vol.

65 ■ July 2017

REVIEW ARTICLE

Concept and Identification of “Soft Bipolarity” in
Patients presenting with Depression:
Need for Careful Screening by Physicians
Pooja Patnaik Kuppili1, Priyanka Yadav2, Raman Deep Pattanayak3

initiated in the general medical
Abstract settings, especially where
The bipolar spectrum is a broader concept, which questions the strict psychiatric services are not readily
available. Therefore, it becomes
dichotomous categorical division of erstwhile manic-depressive
i m p e r a t i ve t h a t p h y s i c i a n s i n
illness into two discrete categories viz. bipolar disorder and major
primary and secondary health care
depressive disorder, thereby overlooking a wide ‘spectrum’ of patients
settings are updated and sensitized
which lie ‘in between’ the two extremes. The presence of underlying
about the various key aspects of
bipolar ‘spectrum’ or ‘soft bipolarity’ often goes undetected in patients
mood disorders in their clinical
presenting with major depression. This sub-group of patients may practice.
not stabilize with indiscriminate use of anti-depressant drugs, and
One such scenario is the presence
without proper management, it may be associated with continued non-
of underlying bipolar ‘spectrum
responsive symptoms, increased suicidality and poorer prognosis. There
disorders’ or ‘soft bipolarity’ which
is a need to suspect and identify such cases of soft bipolarity/spectrum
often goes undetected in patients
by early screening of patients with major depression presenting to
presenting with depression. The
medical settings. The review paper covers the current concepts and review paper covers the current
understanding of bipolar spectrum disorders which is aimed to facilitate concepts and understanding of
early identification, management and referral of cases detected to have ‘spectrum’ and ‘soft bipolarity’
soft bipolarity in the general medical settings. which is aimed to facilitate early
identification, management and
referral, if necessary.
Introduction At least 10% of the patients
visiting primary care physician Relevance for the

M ood disorders are
characterized by a
fundamental disturbance of mood
may have major depression.3
Physicians working in primary
and secondary care settings are
Physicians
Less than 25% of antidepressants
or affect towards either depressive often the first point of contact are prescribed by psychiatrists or
side or elation, along with the for depressive symptoms. Large other mental health specialists.
corresponding changes in the scale recent studies have found More than 70% of antidepressants
activity level, thought etc. In terms that the depressive severity was are prescribed by the general
o f ye a r s l i ve d w i t h d i s a b i l i t y , not different, and symptomatic physicians across most of the
depression is the second leading presentations did not differ world.5 The situation is not
cause of global burden. 1 By the year substantially between primary different in India in the background
2030, depression is projected to be care and specialty settings. 4 Major of wide mental health gap, with
the leading cause of global disease depressive disorder is more similar antidepressants being widely
burden worldwide, highlighting than different among patients at prescribed without the consultation
the public health significance primary and specialty settings. of mental health specialists. The
of mood disorders. Depression Many a times, their treatment is figures are alarming considering
and bipolar disorders together the propensity of antidepressants
account for around 47% of the
DALYs (disability-adjusted life 1
Senior Resident, Department of Psychiatry, JIPMER, Puducherry; 2Senior Resident, 3Associate Professor,
years) contributed by mental and Department of Psychiatry, AIIMS, New Delhi
substance use disorders. 2 Received: 22.02.2016; Accepted: 04.03.2017

also goes on to include: 6 which may pose a hindrance National Comorbidity Survey- • Core. 6.4% for sub-threshold • Associated features including hypomanic symptoms. isolated symptoms. it may prevent and 0. precursors of a full spectrum is not separately specified under any of the traditional These alarming figures thereby disorder or sequelae of a previous nosological systems such as highlight the importance of full disorder. familial U. This strict dichotomy The lifetime prevalence of health gap leading to physicians overlooks a wide ‘spectrum’ of Bipolar disorder . when we focus on the disorders (including those beyond entire spectrum of bipolar disorders. 14 The findings ‘classical’ form of disorder . variety of difficult-to-recognize / conditions. allows and specifies the easy-to-overlook bipolar spectrum bipolar spectrum disorders may diagnosis of one of the spectrum disorders for its diagnostic help us in identifying at-risk disorder viz. it was seen patterns related to core lead to an oversight of important that upto half of the patients with symptoms clinical indicators which may point current diagnosis of depression may towards bipolar spectrum while be bipolar spectrum disorders. relevance. . The DSM. bipolar Bipolarity antidepressants considering the disorder and major depressive double whammy of wide mental disorder.6% for BP-I. or depression arising in the background of cyclothymia. 7-9 Depressed patients that if we consider the prevalence of through the prism appears as a often fail to report past history of entire bipolar ‘spectrum’ disorders. that are usually associated the community setting implying the spectrum concept includes w i t h i n t a c t .S addition. Also. atleast one manic episode) is 1% employed by the pharmaceutical Bipolar spectrum is thus a in general population surveys. Journal of The Association of Physicians of India ■ Vol.7 to mania in BP-I) lasting at least to significant socio occupational The bipolar spectrum is a four days in addition to major dysfunction. but also a wide pay attention to these spectrum Statistical Manual (DSM). Understanding the classical mania as well). there is a need to Diseases (ICD) or Diagnostic and bipolar disorder. were further replicated in U. leading continuum/spectrum of disorders. rainbow spectrum of colors. lack of awareness of spectrum on applying the broader criteria for symptom clusters & behavioral concept amongst physicians may ‘spectrum’ bipolarity. defined providing care to depressed patients patients which lie ‘in between’ the as presence of depression and and vigorous marketing strategies two extremes.1% since the focus is on treatment of • Atypical symptoms related to the physical illnesses. it is necessary to have a current in persons with underlying of a single group of drugs for a or past hypomania (as opposed predisposition to bipolarity.I (BP-I.S. as this approach for however.4% and 1. 65 ■ July 2017 81 causing a “switch” to mania providing a rationale for the use II. From a medical International Classification of focusing not only on the ‘classical’ perspective. 12 companies broad inclusive term for bipolar However. described disorder being 1. 10 • T e m p e r a m e n t a l and/or treating depression. bipolar II disorder. o r e ve n e n h a n c e d that the sub threshold cases are th e b r o a d a r e as of p s yc hiat ric fu nct ioning . lessen morbidity and For making a diagnosis of Bipolar public health importance. and as high as prototypic configuration proactive questioning about past 2.4% in a medical/psychiatric perspective. where bipolarity or hypomania arising due these landmark studies revealed the visible light after passing to treatment. From subthreshold hypomanic symptoms it was found to be about 6. 10 The clinic visit s atleast five times more common phenomenology relating to a given are made mainly with prominent than BP-I and BP-II. So we the prevalence is much higher. In medical settings. defined as presence of Disorder (and ‘Soft to encompass sub-threshold. scale epidemiological survey in The spectrum is a term hyperthymic temperament.15 In terms of clinic prevalence. signs. broader concept. the BPD. depression and atleast a hypomania) short duration hypomanic Bipolarity) was found to be 1. and questions depression. subthreshold and subclinical Replication study with the lifetime for the diagnosis of bipolar symptoms of the classically and 12-month prevalence estimates spectrum. Timely and accurate diagnosis may personality traits facilitate improved management Spectra of symptoms may be Currently the entity of bipolar and outcome for these patients. but in depressive symptoms each time. 1. prodromal. 13 The secondary analyses from borrowed from physics.8% for B P-II.0% and 0.67% in a large- symptoms. The Concept of ‘Spectrum’ can understand bipolar spectrum prevalence for the bipolar disorder II (BP-II. 11 Hence the concept of soft the strict categorical division of bipolarity is of greater importance erstwhile manic-depressive illness Prevalence of and relevance to the physicians by the third edition of DSM-III into ‘Spectrum’/‘Soft’ to promote judicious use of two discrete categories viz. and clinical as well as population.

If no items from criterion C hypomanic level. 22 The 8. A t y p i c a l d e p r e s s i v e for sleep etc may help delineate spectrum disorders’ have described symptoms (DSM-IV the subgroup of patients with the various subtypes of bipolar criteria) bipolar spectrum who present disorder from I to IV (Box 1). non depressed clinical signs or pointers of soft too fast or that you were too ‘hyper’ state) bipolarity are shown in box 2. 17 depressive episode (<25 lability may help identify bipolar II More recently. and • Post partum depression Bipolar III . Antidepressant-induced of bipolarity or treatment induced manic or manic mixed states. • Onset of hypomania after Screening for Soft-Bipolar/ antidepressants similar to. the hypomania. or both Akiskal and Mallya. #Hyperthymic temperament is proposed to bipolar disorder significance as of now. months) researchers. elated mood. by Ghaemi and co. Either of the following. 16 Akiskal& Pinto 17 and even few hours at times) with episodes (on average. 65 ■ July 2017 Box 1: Bipolar spectrum disorders: Box 2: Clinical Signs pointing towards Perug i and Ak isk al l a t er on Akiskal and Pinto (1999) “soft bipolarity” have further expanded soft Bipolar I . r e ve r s e d Plus 1 item from criterion D same as bipolar spectrum (only vegetative symptoms like should be present difference being that the Bipolar I hyperphagia and hypersomnia subtype is excluded from rubric of during depression instead of 1. • Loss of response on antidepressant Bipolar Spectrum drugs Key Diagnostic Schema • 3 or more Antidepressants tried. 18 The chief Along with these presence of the following attributes of soft bipolarity are o f a t y p i c a l s y m p t o m s .19 than your usual self?”  . 21 Asking just a few Key diagnostic schema of BSD episodes (>3) more questions focusing on any were given by researchers. • First episode of major depression eating disorders with underlying emergent hypomania before 25 years of age c y c l o t h y m i c . B r i e f m a j o r d e p r e s s i ve Klerman. Recurrent major depressive paper in JAPI.Depression and mania • Four or more recurrent episodes of bipolarity encompassing a variety Bipolar II . impulse control. The your friends told you were talking (at baseline. Early age of onset of major A two-question screen for mood proposed as well. Patients with soft enquired about. At least one major depressive response “Are you a person who frequently episode experiences ups and downs in 9. Post partum depression response to at least one question bipolar spectrum disorders as indicating mood lability. Antidepressant “wear off” follows: questions are as follows: (acute but not prophylactic A.Depression and treatment. Psychotic major depressive to the physicians with current Additionally. The severity of h i s t o r y o f e l e va t e d m o o d a n d relative elated phases never reaches level of increased activity. “pseudo-unipolar depression”. and mania or hypomania mood symptoms should be remains at clinical or sub.a n x i o u s .Depression and discrete major depression of conditions ranging from mood. Ghaemiet al 9 years) disorder patients if there is positive proposed diagnostic criteria for 7. 3. the types I 1/2. along with a set of attributes. plus 2 without cause?” soft bipolarity was first given by items from criterion D. family history 2. 9 Akiskal and Pinto in overactive and decreased need their landmark paper on ‘bipolar 4.s e n s i t i ve Bipolar IV . No spontaneous hypomanic or mood over life?” more antidepressant trials manic episodes “Do these mood swings occur The closely related concept of C. Hyperthymic personality may go undetected for years. none The screening of patients for of Bipolar Spectrum/Soft worked depression has been discussed in • Highly seasonal mood shifts more detail in a previous review Bipolarity 2. but more stable than. and feeling so happy or energetic that 1. 5. ½ . brief (less than 3months) disposition. mood reactivity and context of hyperthymic temperament depressive episodes interpersonal sensitivity. hypomania • Psychosis during major depression anxiety. II episodes depressive symptoms.6 of the following bipolarity are often referred to as such as:“Have you had periods of 9 criteria are needed.Depression (late-life) in • Multiple. past disorder in a first degree bipolar spectrum). using questions are present. A family history of bipolar soft bipolarity while included in loss of appetite and sleep. 82 Journal of The Association of Physicians of India ■ Vol. feeling over-energetic. Lack of response to 3 or B.threshold D. notably periods (few days to few weeks. 20 be characterized by an excessively positive • Hyperthymic personality disposition. though *Hypomania: a milder form of mania usually • Atypical depressive symptoms • First-degree relative has diagnosis of this concept is more of research lasts few days with no marked dysfunction. V and VI have been 6. III1/2 .< 3 more recently. 18.

there is a definite need for Treatment Principles and the physicians to be wary of the need for Referral Implications for Under. It has 17 • I n k n o w n b i p o l a r I destabilization of mood. The patients The cases with suspected clinical should be done in all patients with bipolar spectrum often fall pointers of spectrum/ soft bipolarity presenting with major depressive prey to unscrupulous prescribing should be identified and sent for an episode in a busy outpatient of antidepressants which may expert opinion. anti-depressant-induced .26 easily clinched on cross-sectional assessing depressed patients. as sleep. Journal of The Association of Physicians of India ■ Vol. overemphasized. These should be setting. there is • Use of tricyclic antidepressants physicians 30% of the patients a definite risk of over diagnosis in patients with suspected were found to be having bipolar and unnecessary exposure to “pseudo-unipolar” depression disorder. referred to a psychiatrist for further evaluation and management. the concept of have found that a score ≥50 had ‘soft bipolarity’. Hence. 24 mania/hypomania in pre. Patients with signs of bipolar spect rum not b eing • In case of a definite ‘switch’ particularly emphasized. 23 mood stabilizers and antipsychotic should be avoided as they carry The Bipolar Index is another a higher risk for a ‘switch’ medication. and national incidence. clinical profile of full spectrum of bipolarity. Caution is also needed assessment tool which evaluates than the Selective Serotonin regarding the potential risks of across five domains namely signs Reuptake Inhibitors (SSRIs) o ve r d i a g n o s i s . anti-depressant induced is one of the most commonly affective episodes. and increased risk of these symptoms. general physicians in the recent Screening using the relevant disposed individuals. While majority of the patients treatment attending family remain under diagnosed. symptoms. “Primum non nocere”. therefore identification and delineation screening instruments in the busy the hypomanic or subthreshold of the early symptoms of outpatient setting is again a matter symptoms are often missed. In case of switch. 1990–2013: a a risk of incomplete or inadequate systematic analysis for the Global Burden remission. • In cases with Bipolar II or III. and used screening tool. w h i c h i s a l s o and symptoms. Misdiagnosing bipolar spectrum the decision may have to be References as pure depression has its own made to initiate the long-term share of risks as majority of 1. suicidality. age of onset. Injudicious questions pertaining to hypomanic patients. 65 ■ July 2017 83 Mood Disorder Questionnaire drug.27 There exists for 301 acute and chronic diseases and or an atypical antipsychotic injuries in 188 countries. antidepressant must be stopped to the current nosological status euphoria etc) immediately. antidepressants use of antidepressants in cases with symptoms. in order to prevent future switch. poor prognosis and diagnostic interviews were applied especially if depressive adverse psychosocial outcomes. Global. • F a m i l y m e m b e r s s h o u l d Though screening instruments presentation of patient rather than be psychoeducated about are available. valproate etc) antidepressants alone. presence of several s h o u l d b e p r e s c r i b e d ve r y underlying bipolarity may also of these symptoms in the same judiciously and for short-term lead to continued subthreshold time duration and the impact of u n d e r t h e c o ve r o f m o o d . of a thorough history to rule out to mental health professional the dose of antidepressant past history of any hypomania conforming to the principle of drugs must be immediately or elated mood state cannot be medical ethics of non-maleficence- reduced or stopped. increased energy. times owing to their clinical and clinical questions or instruments public health burden. When structured stabilizing medication. course and Bupropion. and years lived with disability (such as lithium. response to treatment. Some general principles for Recognition and Under- Some of the “soft pointers” managing the suspected cases of Treatment towards bipolar spectrum soft bipolar or bipolar spectrum As the diagnosis may be more should be kept in mind while disorders are as follows: 19. 25 lead to devastating consequences. spectrum and soft bipolarity is good sensitivity and specificity for deprivation can precipitate of increasing importance to the identifying bipolar disorders.29 to patients on antidepressant symptoms are mild. detrimental. rapid cycling and mixed state. of illness. the feasibility of the longitudinal history. The role of soft bipolarity may be referred from depression to hypomania. Patients hypomania (decreased need of concern. regional. Conclusion • Ensure a regular sleep-wake and family history and researchers cycle to all patients with To conclude. treatment with mood stabilizer these patients get treated with prevalence. the are often left in the “shadow” due for sleep. 28.

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