When I was training in the 1990s, diagnosing bipolar disorder seemed straightforward. These patients often came to our attention because of a flagrant manic episode. You may still remember the first time you treated a manic patient—I certainly do. He was a man in his 20s with flowing red hair and a messianic beard, who was admitted after police found him doing cartwheels on the highway during rush hour. He told me, in an ebullient rush of language, that he was Jesus Christ and therefore invincible—as “proven” by the fact he’d survived his highway stunt.

Seeing such patients may have given us the impression of a clear distinction between those who experience depressive episodes interspersed with mania, and those who are just depressed. But over time, that distinction has become less clear. In this issue, Dr. Chris Aiken describes the many variations of presentations that land on the “bipolar spectrum,” including bipolar I and II, cyclothymia, depression with mixed features, depression with short-duration hypomania … and so on. Dr. Aiken has no agenda and is hardly advocating that anyone with a whiff of bipolar disorder must be put on lithium or atypical antipsychotics. But he reminds us that mood disorders lie on a continuum and that making categorical distinctions is often not helpful. His is a thoughtful approach and one that I hope you’ll find useful in your practice.

Best,
Danny
dcarlat@thecarlatreport.com