Evidence-Based Reviews

How to treat PTSD in patients with comorbid mood disorders

Current Psychiatry. 2010 April;9(4):48-61

Antidepressants may trigger hypomania in patients with bipolar spectrum disorders

References

1. Kessler RC, Berglund P, Demler O, et al. The epidemiology of major depressive disorder: results from the National Comorbidity-Replication (NCS-R). JAMA. 2003;289:3095-3105.

2. Kessler RC, Sonnega A, Bromet E, et al. Posttraumatic stress disorder in the National Comorbidity Survey. Arch Gen Psychiatry. 1995;52:1048-1060.

3. Franklin CL, Zimmerman M. Posttraumatic stress disorder and major depressive disorder: investigating the role of overlapping symptoms in diagnostic comorbidity. J Nerv Ment Dis. 2001;189:548-551.

4. Akiskal HS, Mallya G. Criteria for the “soft” bipolar spectrum: treatment implications. Psychopharmacol Bull. 1987;23:68-73.

5. Benazzi F. Prevalence of bipolar II disorder in outpatient depression: a 203-case study in a private practice. J Affect Disord. 1997;43:163-164.

6. Akiskal HS, Benazzi F. Optimizing the detection of bipolar II in outpatient private practice: toward a systematization of clinical diagnostic wisdom. J Clin Psychiatry. 2005;66:914-921.

7. Akiskal HS, Akiskal KK, Lancrenon S, et al. Validating the soft bipolar spectrum in the French National EPIDEP study: the prominence of BP-II. J Affect Disord. 2006;96:207-213.

8. Rabakowski JK, Suwalska D, Lojko D, et al. Bipolar disorders among Polish psychiatric outpatients treated for major depression. J Affect Disord. 2005;84:141-147.

9. Benazzi F. Bipolar disorder—focus on bipolar II disorder and mixed depression. Lancet. 2007;369:935-945.

10. Diagnostic and statistical manual of mental disorders, 4th ed, text rev. Washington, DC: American Psychiatric Association; 2000.

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Major depressive disorder (MDD) and bipolar spectrum disorders are associated with some symptoms of—and fully defined—posttraumatic stress disorder (PTSD). Many traumatic experiences can lead to this comorbidity, the most common being exposure to or witnessing combat for men and rape and sexual molestation for women.1

Trauma has major prognostic and treatment implications for affectively ill patients, including those whose symptoms do not meet PTSD’s full diagnostic criteria. This article aims to help clinicians by:

presenting evidence characterizing the overlap between affective disorders and PTSD
reviewing evidence that the bipolar spectrum may be broader than generally thought, an insight that affects PTSD treatment
making a case for routine PTSD screening for all patients with affective illnesses
recommending PTSD treatments tailored to the patient’s comorbid affective disorder.

Overlap of trauma and affective illness

PTSD is remarkably comorbid with mood disorders. Americans with MDD and bipolar disorder (BPD) are 7 and 9.4 times, respectively, more likely to meet criteria for PTSD than persons in the general population, according to odds ratios Kessler et al² calculated from the National Comorbidity Survey database.

I have never seen a patient with PTSD who did not also meet criteria for an affective disorder. The concurrence of PTSD and MDD is not the product of overlapping diagnostic criteria. Rather, evidence indicates these are distinct diagnostic entities.³ A review of diagnostic criteria for PTSD and hypomania/mania leads to the same conclusion.

Bipolar spectrum disorders

DSM-IV-TR assumes that mood disorders fall neatly into boxes. Other data (Table 1)^4–8 indicate that these disorders fall along a continuum or—more conservatively—that the scope of bipolarity is much wider than DSM-IV-TR recognizes. This is a controversial topic, and the individual clinician’s position could impact how one manages PTSD patients.

Table 1

Evidence of bipolar spectrum features in major depressive episodes

Study	Design	Conclusion
Akiskal and Mallya, 1987⁴	200 community mental health clinic patients diagnosed as having MDD	50% could be classified as having a bipolar disorder
Benazzi, 1997⁵	203 consecutively presenting patients with depression	45% met criteria for bipolar II disorder
Akiskal and Benazzi, 2005⁶	563 consecutive patients presenting with a DSM-IV-diagnosed MDE	58% showed features of bipolar II disorder
Akiskal et al, 2006⁷	493 patients in a French national study presenting with MDE	65% were determined to fall along the ‘bipolar spectrum’
Rabakowski et al, 2005⁸	880 Polish outpatients presenting with MDE	40% met criteria for bipolar disorder
MDD: major depressive disorder; MDE: major depressive episode

In this article, I include bipolar I disorder, bipolar II disorder, and mixed depression within the “bipolar spectrum disorders.” If one accepts this—and I do—it follows that 50% to 70% of all major depressive episodes (MDEs) are bipolar in nature.^4–9 Depending on your practice setting, you may see a higher or lower base rate of bipolar spectrum disorders.

Mixed depression is not recognized in DSM-IV-TR, and the purpose of this article is not to defend its inclusion as a bipolar spectrum phenomenon. A proposed definition of mixed depression⁹ requires the presence of an MDE contaminated by ≥3 features of hypomania or mania, without euphoria or inflated self-esteem/grandiosity (Table 2).¹⁰

Clinical Point

Validation studies suggest that mixed depression is a bipolar variant

Some experts believe episodes of hypomania and mania frequently occur in the illness course of persons with mixed depression; indeed, mixed depression is a predictor of a bipolar course. It is observed in outpatient⁹ and inpatient settings.¹¹ Common forms of mixed depression feature combinations of irritability, psychomotor agitation (mild to severe), increased talkativeness (which may fall short of frank pressured speech), racing or “crowded” thoughts (or “mental overactivity”), and distractibility. Other than increased self-esteem/grandiosity, any symptoms within DSM-IV-TR criterion B for a hypomanic or manic episode may be seen in mixed depression. Psychosis is an exclusion criterion for mixed depression.

Mixed depression responds poorly to antidepressant monotherapy. Validation studies suggest that mixed depression is a bipolar variant, as determined by its capacity to predict a bipolar course and its association with a family history of bipolar disorder and age of onset.⁹

Table 2

Diagnostic characteristics of a hypomanic episode, DSM-IV-TR criteria A and B

A. A distinct period of persistently elevated, expansive, or irritable mood, lasting throughout at least 4 days, that is clearly different from the usual nondepressed mood.
B. During the period of mood disturbance, 3 or more of the following symptoms have persisted (4 if the mood is only irritable) and have been present to a significant degree: 1) inflated self-esteem or grandiosity 2) decreased need for sleep (eg, feels rested after only 3 hours of sleep) 3) more talkative than usual or pressure to keep talking 4) flight of ideas or subjective experience that thoughts are racing 5) distractibility (ie, attention too easily drawn to unimportant or irrelevant external stimuli) 6) increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation 7) excessive involvement in pleasurable activities that have a high potential for painful consequences (eg, the person engages in unrestrained buying sprees, sexual indiscretions, or foolish business investments).
Source: Diagnostic and statistical manual of mental disorders, 4th ed, text rev. Washington, DC: American Psychiatric Association; 2000